1. Energize your MDS: Database Accuracy and Analytical Reports

2. Leah Klusch, RN, BSN, FACHCA Executive Director The Alliance Training Center Alliance, Ohio 330-821-7616 leahklusch@sbcglobal.net PRESENTED BY

3. Rules and Risk O Every time the rules change the industry must respond with careful action. O The entire assessment process has changed and this impacts the documentation and the data base for every facility in the country. O Some regulators have said this is just a minor change – they are very wrong - either they do not understand the scope of the process or they do not understand facility operations. O THE CHANGE TO THE MDS 3.0 IS A BIG CHANGE !

4. New Data Base – New Timing O All of the changes are going to impact the regulatory process and the format of surveys in the future. O The data base that the surveyors and intermediaries are using now is very rich and the was created to serve the process both regulatory and payment. O Facilities must understand the data base and use considerable operational energy to monitor their data as it will continue to define the provider and create the payment for Part A Medicare and Medicaid in many states.

5. New Data Base – New Timing O The timing of the assessment tasks, transmission and billing for services are now more connected than ever before. O The big factor is the assessments and bills for Part A Medicare services are going into the same server. O Timelines for assessments and transmission have changed and are more aggressive. O More assessments will be done in most facilities and more data will be included in the facility data base in the federal server.

6. FACT CAREFUL OBSERVATIONS OF MDS NURSES HAVE SHOWN THAT IT TAKES AT LEAST 35% MORE TIME TO COMPLETE THE MDS 3.0 – CONTRARY TO THE STATEMENTS FROM CMS IN THE SPRING OF 2010.

7. RULES ? What Rules? O Two issues related to the rules and the regulatory process. O Medicare plans to police the rules more carefully by using more data analytics in their server to screen assessments and bills. O The rules for coverage of services are being addressed more frequently in RAC Audits and other oversight activity. O Do you have a copy of the Medicare Benefit Policy Manual? O Do you know what this reference is and who needs to read it?

8. None of the regulatory tags have changed but the type and intensity of data flow has increased from the 2.0to the 3.0 process However….The rules for data collection – the timelines for data collection, the definitions within the manual, the types of assessments and the requirements for doing and transmitting the assessments are very different, more detailed and frequently require more staff time. RULES ? What Rules?

9. Regulatory Oversight O Regulatory oversight of the assessment process and evaluation of compliance with the new data collection processes and policies will be much easier. O CMS will continue to roll out the QIS Survey process throughout the country – which relies on the data base to highlight issues with negative outcomes and negative patterns of care. ( You may try to run but you can not hide )

10. Ask yourself these questions… Who is responsible for the data flow in our facility into the assessment process and then into the federal data base? Is the training and preparation of our team adequate ? Where are the manuals ? Are they updated? If our data base is wrong……..what is the risk? Do our managers understand the importance of the assessment process and its details ? How about hardware and software?

11. New Style on Data O Many of the data items on the MDS 3,0 data base are outcome oriented and have more specific definitions related to outcomes or specific scoring that shows positive and negative outcomes over time. O Now we are reporting interviews regularly related to cognitive function, signs of depression and the resident’s perception of pain. O Two of these interviews create a numeric scores which will be compared from assessment to assessment. O The facility should be able to track the impact of the care plan interventions in the data base over time.

12. REGULATORY STRATEGIES O Know the rules – The regulatory TAGs and the structure and process of the assessment. O This will require resources – time and direction from operations. O The MDS is not a nursing tool- It is a regulated interdisciplinary functional assessment. O Have open discussions with all team members. O Clinical and operational leadership are essential. O Stay informed about the QIS implementation in your state – or 3.0 data base use with the traditional survey.

13. The Focus on Outcomes O Much of the data has implications for outcome reporting or directly reports outcomes each time an assessment is done. O The MDS 3.0 has more measurements, comparisons and data flow between assessments. O The MDS 3.0 builds a more comprehensive data base at the point of the admission and then points to the changes with self reporting or specific reporting of changes from assessment to assessment. O The facility needs to monitor outcomes reported into the data base…..so you need to know your data.

14. O Outcomes can be measured in two ways in the new data base. O Stated outcomes on the assessment - is the resident or the issue the same – better or worse items. O Comparison of data from one assessment to the next – BIMS score from one assessment to the next etc. O Item scoring that shows outcomes – continence tracking, skin issues, or behavior coding by indicating the frequency of occurrences. The Focus on Outcomes

15. Look at the proposed QI/QMs O The theme is still outcomes. O Now we have more data that more clearly defines the progress of the resident. O Customer satisfaction issues with the new data base that will need to be defined. O Monitor the progress of the resident in Rehab and or skilled nursing programs. O Definition of long and short stay populations.

16. Assessment Types and Schedules O Most managers do not understand the large changes in this area. O Many more assessments are being done and if they are not on time compliance and payment issues occur. O It is important to monitor the number and types of assessments being done weekly as well as validation activity. O Delayed assessments could be default rate or no payment.

17. Question Every time a resident goes to the hospital and is admitted and then discharged back to the facility……. How many pages of assessments are required to be transmitted and validated?

18. DOES THIS CHANGE IN ASSESSMENT PROCESS HAVE A LARGE IMPACT ON THE EFFICIENCY AND WORK LOAD OF YOUR ASSESSMENT TEAM? WHO MANAGES THIS ACTIVITY ?

19. Be Aware.. O Be aware that this is a very complicated process. O IF YOU DO NOT BELIEVE THIS TRY TO READ CHAPTER 2 OF THE MDS MANUAL. O Some of the processes still need to be clarified by CMS - the new system is complicated and very task intensive. O Scheduling is very important and must be communicated to the entire IDT and then the staff so everyone is focused on data collection and accuracy. O Problems with completion and transmission of assessments will produce problems with payment.

20. MDS OFFICE EFFICIENCY O Training needs to be on going and very complete. O Competency is essential – Training with testing is very important. O Evaluate the location, supplies and software issues. Monitor training quality from software vendors – sit in on training and look for clear directions and supporting written tools. O Evaluate employee satisfaction - discuss the problems – LISTEN TO THE STAFF.

21. ISSUES THAT IMPACT PAYMENT O The entire team needs to understand the payment process changes from RUG III to RUG IV. O RUG distribution is important - identifies the resident and service types in the facility. The team must know the MDS items that qualify cases for payment – Rehab and Nursing. O Payment levels per day for RUG groupings need to be discussed by the IDT and at U.R. Meetings. O Many teams do not utilize a variety of payment groupings on Part A Medicare cases. RUG IV is not all about Rehab only - Believe me!

22. Monitor Coverage Decisions O Monitor coverage decisions – Remember the quote in the RAI Manual Chapter 3, Section O page 14……..The physician, the qualified therapist and nursing administration have the responsibility to determine the quantity, duration and intensity of therapy services. O We now have a more flexible payment categories and payment levels that more accurately cover skilled services. O Accuracy of MDS and Universal Bills – result – no payment if mismatched data O Simple errors can stop payment of Part A Claims….quote from RAI Manual chapter 6 p. 6-6.

23. Remember O Remember all payment for Part A Medicare is the responsibility of the facility – You must monitor your contractors. Know the services they are delivering and reporting through the MDS data base. O Monitor all Medicare payments - follow up with any delayed or denied payments or requests for information. O Check that billing is using the correct billing manuals and processes. O ADL scores accuracy and influence on overall payment levels – Biggest issue related to payment in most facilities.

24. THEN WE HAVE ADL SCORES! O If you are tired of this discussion – Get over it. O Fact – Every MDS data set creates an ADL score – which is recorded in the data base and utilized to evaluate the case, stay and payment. O ADL tracking during the assessment reference period is required and must be accurate –I am sure you have heard this before……. O It is true and must be addressed by operations because of the risk to the facility from wrong scores.

25. SO WHAT HAS CHANGED ? O The focus on ADL scores as a primary indicator of functional decline is very strong.. O That means: O What is the ADL score on admission for a Rehab case – It must show functional loss. O How does the ADL score change during the Part A stay with Rehab services. O Does the ADL score match the other functional performance codes in the data set. O Are ADL score values documented and discussed as part of the Utilization Review Process.

26. There is more to the changes…. O ADL calculations have been changed and the value of some self performance codes has been lowered in the calculation. O This means that self performance scores with a Limited Assist code add less point value to the total ADL score under RUG IV than RUG III. O The ADL levels that change payment rates within the RUG categories are now different and the IDT must monitor functional changes so that the reported ADL values are accurate.

27. 2.0 to 3.0 ADL Score Calculation MDS 2.0 ADL CalculationMDS 3.0 ADL Calculation Bed Mobility22ADL Pts 3 Transfer22ADL Pts 3 Eating11ADL Pts 1 Toilet Use22ADL Pts 3 Bed Mobility22ADL Pts 1 Transfer22ADL Pts 1 Eating11ADL Pts 0 Toilet Use22ADL Pts 1

28. MDS 2.0 ADL CalculationMDS 3.0 ADL Calculation Bed Mobility32ADL Pts 4 Transfer32ADL Pts 4 Eating12ADL Pts 1 Toilet Use32ADL Pts 4 Bed Mobility32ADL Pts 2 Transfer32ADL Pts 2 Eating12ADL Pts 2 Toilet Use32ADL Pts 2 2.0 to 3.0 ADL Score Calculation

29. MDS 2.0 ADL CalculationMDS 3.0 ADL Calculation Bed Mobility 33ADL Pts 5 Transfer33ADL Pts 5 Eating11ADL Pts 1 Toilet Use32ADL Pts 4 Bed Mobility 33ADL Pts 4 Transfer33ADL Pts 4 Eating11ADL Pts 0 Toilet Use32ADL Pts 2 2.0 to 3.0 ADL Score Calculation

30. Some ADL Rules That Work O On admission to Skilled Rehab the elder must exhibit functional decline – An ADL score of 10 or more on the admission assessment is very safe for most situations. O ADL coding must be scored from 24 hours of staff documentation during the assessment reference period – usually 7 days. O ADL documentation from the front line staff must become part of the medical record to substantiate the ADL score in the MDS data base.

31. ADLs O As the elder progresses in the Rehab program changes in the ADL score should be correlated with the gains in strength and skill. O ADL scores should be reported and discussed at Utilization Review Meetings. O Staff learn about ADL definitions and coding formats in orientation programs at the time of hire. O IDT members need to know the impact of ADL scores on payment groupings and the $ value of payment levels.

32. Changes in Payment O Importance of RUG distribution reports with ADL scores. O Report of RUG and ADL for an individual case O Report of all Medicare Part A cases for the entire facility O Report of RUG distribution for the total census of the facility. O Track RUGs by the week, month and quarter looking for trends and outcome documentation.

33. Be careful to…….. O Do Mood interview according to the steps in the RAI manual so the scores are relative and valid – MSS of 10 or over will have positive impact on Nursing RUGs payment. O Only code infections if they qualify in the 2007 CDC Guidelines – Manual page 0-4 for reference. O Monitor ADL scores during the assessment reference period - Low scores on 5 and 14 day assessments could be a problem.

34. Make Certain.. O Make certain that the team doing admissions understand the new qualifiers into the nursing RUGs – this is a very rich area for coverage and services for a broad population. O Track each Part A admission and be sure that the team understands about the possibility of doing more than one RUG during the stay. O Look for weight bearing assist for tracking ADL activity. Focus on evening and night shift documentation.

35. Audit Rehab Services O Audit rehab services between assessment reference periods to document consistent delivery – if rehab services or intensity of services change then the plan and the Dr.s order needs to change as well. O Follow the Rehab documentation rules in the MDS manual – Chapter 3, Section O, page 15 to 30. O Check that billing is using the same data for the Universal Bill as the MDS has documented – problem area – focus on Dx. Dates and services.

36. Training – Live & Online O Continue to provide training to your MDS office staff and members of the IDT. O Live training is very helpful but check out the session before you attend to confirm that the material has updated accurate information. O On line training is very practical and flexible for facility staff – suggest Redilearning.com as a resource.

37. Questions?

38. Thank You! For more information on Leah’s online MDS 3.0 program, go to: redilearning.com http://redilearning.com/skill ed-nursing-mds-30.asp http://redilearning.com/skill ed-nursing-mds-30.asp