1. 1 MDS 3.0 – Changes in the Survey Process By Haideh Najafi, RN, BSN, MSED, EDS And Tedi Beckett, RN, MSN September 15, 2010

2. 2 Objectives  Describe the difference between MDS 2.0 and MDS 3.0.  Describe the effect of MDS 3.0 on the survey process.  Identify possible citations resulting from deficient practices regarding MDS 3.0.

3. 3 Important! MDS 3.0 will replace MDS 2.0 on Oct 1, 2010.

4. 4 Goals of the MDS 3.0  Introduce advances in assessment measures.  Increase the clinical relevance of items.  Improve the accuracy and validity of the MDS tool.  Increase the resident’s voice by introducing more resident interview items.

5. 5 Goals of the MDS 3.0 (continued)  Increase the reliability, efficiency, and usefulness of the MDS.  Use standard protocols used in other settings.  Improve clinical assessment.

6. 6 MDS 3.0 RAI MDSCAA (RAPs) Utilization guidelines

7. 7 Purpose of the CAA Process Identify potential resident conditions and issues. Identify risks and causes of resident conditions.

8. 8 Comparison of MDS 2.0 & 3.0 MDS 2.0MDS 3.0 RAPCAA There were 18 RAPs in MDS 2.0 of the RAI. There are 20 CAAs in MDS 3.0 of the RAI, which includes the addition of “PAIN” and “Return to community.”

9. 9 Changes in Selected MDS Sections Section J – Health Conditions (Pain) Section M – Skin Conditions Section O – Special Treatments, Procedures, & Programs Section P – Restraints Section Q – Participation in Assessment & Goal-Setting

10. 10 Comparison of MDS 2.0 & 3.0 Section J – Health Conditions Pain assessment requires asking the resident detailed questions about: Pain frequency. Effect of pain on the resident’s function. Numeric scale and description of the pain. Section J requires staff to answer questions about non-verbal indicators of pain and about the resident’s pain medication regimen.

11. 11 MDS 3.0 - Section J Health Conditions (continued) Falls Prior to Admission and Falls Since Admission Defines “injury” and “major injury” If the resident has fallen since admission, the number of falls in which there was injury or major injury must be coded.

12. 12 Comparison of MDS 2.0 & 3.0 Section M: Skin Conditions MDS 2.0MDS 3.0 Does not include this information. Determination of Pressure Ulcer Risk Does not include this information. Unhealed pressure ulcer

13. 13 Comparison of MDS 2.0 & 3.0 Section M (continued) MDS 2.0MDS 3.0 Does not include this information. Number of pressure ulcers present on admission or re-entry Does not include this information. Description and number of unstageable pressure ulcers

14. 14 Comparison of MDS 2.0 & 3.0 Section M (continued) MDS 2.0MDS 3.0 Does not include this information. Dimensions of unhealed or unstageable stage 3 or 4 pressure ulcers Does not include this information. Most severe tissue type for any pressure ulcer

15. 15 Comparison of MDS 2.0 & 3.0 Section M (continued) MDS 2.0MDS 3.0 Does not include this information. Worsening in pressure ulcer status since prior assessment Does not include this information. Healed pressure ulcer since last assessment

16. 16 Comparison of MDS 2.0 & 3.0 Section M (continued) MDS 2.0MDS 3.0 Does not include this information. Number of Venous and Arterial Ulcers Other skin problems or lesions present Other ulcers, wounds and skin problems, including foot problems

17. 17 Reverse staging/backstaging Current clinical standards do not support reverse staging or backstaging. PastNow If a pressure ulcer was healing such that it was less deep, wide, and long, it was permitted to reverse stage or backstage it in the documentation. A healing pressure ulcer is documented as its highest stage until it has completely healed.

18. 18 Comparison of MDS 2.0 & 3.0 Section O: Special Treatments, Procedures, and Programs MDS 2.0MDS 3.0 Does not include this information. 1. Influenza vaccine 2. Date that the resident received the influenza vaccine 3. Reason why the resident did not receive this vaccine Does not include this information. 1.Pneumococcal vaccine 2.Reason why the resident did not receive the vaccine

19. 19 Comparison of MDS 2.0 & 3.0 Section O (continued) MDS 2.0MDS 3.0 P.T., O.T., S.T., R.T., and psychological therapy record the number of days and total minutes the therapy was provided. P.T., O.T., S.T., record the total number of minutes that any of these therapies were administered to the resident individually, concurrently with one other resident, or as part of a group of residents.

20. 20 Section P: Restraints  The intent of this section is to record the frequency that the resident was restrained by any of the listed devices at any time during the day or night.  Physical Restraints now codes restraints “used in bed” and “used in chair or out of bed” separately.

21. 21 Section Q: Return to the Community MDS 2.0 MDS 3.0 Discharge potential item asked the assessor if the resident expressed a preference to return to the community. Return to community referral item asks the individual (resident) if he/she is interested in speaking with someone within 10 business days about the possibility of returning to the community.

22. 22 Section Q (continued) MDS 2.0MDS 3.0 The assessor’s findings were recorded in the database and no follow-up action was required. If the individual responds Yes, then the facility must initiate care planning and refer the individual to a state-designated local contact agency (LCA).

23. 23 Section Q (continued) MDS 2.0MDS 3.0 Determined if the resident had a support person who was positive toward discharge. A more extensive series of questions for assessment and investigation for care planning are asked. Asked only upon admission and annually Asked at admission, annually, quarterly, and on significant change assessment

24. 24 How does MDS 3.0 affect the survey process? There will be changes in: a) Sample selection. b) Validating interviews. c) Care Area Assessment (CAA) process. d) The tasks & the SOM.

25. 25 Important! During an interim period after MDS 3.0 is implemented, the QI/QM reports will not be available to facilities or surveyors. This interim period may last up to one year (or longer).

26. 26 How will this affect the survey process? The survey process will go back to the 1995 survey procedures until QI/QM data become available.

27. 27 Are the CMS forms changing? Yes, CMS is changing some of the survey forms. The Roster/Sample Matrix (CMS 802) The Roster/Sample Matrix Provider Instructions (CMS 802P) The Roster/Sample Matrix Instructions for Surveyors (CMS 802S) The Resident Census and Conditions of Residents (CMS 672)

28. 28 Revisions to the Instructions for the Roster/Sample Matrix The Roster/Sample Matrix Instructions for Surveyors (802 S) and Roster/Sample Matrix Instructions for Providers (802 P) have been revised to accommodate the changes (i.e., reference to QM/QI reports were removed).

29. 29 Revisions to the Roster/Sample Matrix  Fall/Fractures is a separate field from Abrasion/Bruises.  Behavioral Symptoms is a separate field from/Depression.  Resident Characteristics have been re- numbered.

30. 30 Are the survey tasks changing?

31. 31 Task 1: Off-site Prep Teams will not be able to generate an off-site sample based on the QI’s during this interim period.

32. 32 Task 1: Off-site Prep (Continued) Issues & the off-site sample will be based on: Ombudsman reports. Facility reported incidents. Preadmission Screening and Resident Review Reports (PASRR). Waivers/Variances.

33. 33 Task 1: Off-site Prep (Continued) CASPER 3 Report (Facility History Profile) (formerly OSCAR reports) CASPER 4 Report (Full Facility Profile) CMS 2567’s since the past standard survey (complaints)

34. 34 Task 2: Entrance Conference Explain that the QM/QI reports will not be run until further notice. Explain that the initial tour may take longer and be more in-depth than in the past.

35. 35 Task 2: Entrance Conference (Continued) Request that the facility complete the Roster/Sample Matrix (CMS 802) by the end of the initial tour. Facilities must complete the 802 and 672 with the information they have in their clinical records, regardless of the availability of MDS information.

36. 36 Task 3: Initial Tour  Confirm or invalidate the pre-survey information and add new concerns that were identified (if any).  Identify potential residents and areas of concern to be investigated.  Attempt to meet as many residents as possible. (It is not necessary to meet 100% of the residents).

37. 37 Task 3: Initial Tour (Continued)  Identify interviewable residents.  Do not rely solely on facility staff regarding which residents are interviewable.  Interview residents, families, and staff members during the tour to identify concerns and potential residents for sample selection.

38. 38 Task 3: Initial Tour (Continued)  Each surveyor will use a Roster/Sample Matrix during the tour to identify care issues.  Record each resident’s: 1) Name 2) Location 3) Areas of concern that relate to each resident

39. 39 Task 4: Sample Selection The phase I sample will be based primarily on residents identified during the initial tour. Phase 1: 60% of the sampled residents will be selected during the initial tour. Phase 2: 40% of the sampled residents will be selected.

40. 40 Task 4: Sample Selection (Continued)  Sample selection should be case mix stratified to capture: Interviewable residents. Non-interviewable residents. Residents receiving heavy care. Residents receiving light care.

41. 41 Task 4: Sample Selection (Continued) Various stages of impairment of: 1) Physical dependency. 2) Functional dependency. 3) Cognitive functioning.

42. 42 Task 4: Sample Selection (Continued) WHP sample selection: Weight loss. Hydration risk. Pressure ulcer.

43. 43 Task 4: Sample Selection (Continued) Residents that are encouraged but not required to be placed on the sample: Those receiving ESRD services Those receiving hospice services Those who are ventilator dependent

44. 44 Task 5: Information Gathering - CAA Process Verify that information obtained and recorded during the structured interviews on the MDS 3.0 is accurate and correct.

45. 45 Resident interview sections  Section C: Cognitive Patterns. Section D: Mood. Section F: Preferences for Customary Routine and Activities. Section J: Health Conditions. Section Q: Participation in Assessment and Goal Setting.

46. 46 Task 5: Information Gathering - CAA Process (Continued) Review Care Area Triggers (CAT’s). All CAT’s do not necessarily require care planning.

47. 47 Task 5: Information Gathering - CAA Process (Continued) Review the documentation that is the basis for the facility’s decision to care plan a CAT or not.  Consider whether the findings on the MDS 3.0 require an intervention.  Consider the rationale(s) for selecting specific interventions.

48. 48 Task 5: Information Gathering - CAA Process (Continued) Surveyors use the “Location and Date of CAA Documentation” column on the CAA summary (section V of the MDS 3.0) to find where the CAA documentation can be located in the resident’s record. Review this documentation.

49. 49 Task 5: Information Gathering - CAA Process (Continued) The documentation of the CAA findings and decision–making process may appear anywhere in a resident’s records “e.g: flow sheets, progress notes, care plan summary, CAA narrative.”

50. 50 Task 5: Information Gathering - CAA Process (Continued) Look for evidence that the information from the resident’s interviews has been incorporated into a care plan (especially from section Q).

51. 51 Task 6: Decision-Making Regarding MDS 3.0 F-168 - Right to receive information from agencies acting as client advocates and be offered the opportunity to contact these agencies. Cite if the facility did not make a referral to the LCA within 10 business days of the resident answering “Yes” to Q0500A. The facility must follow-up with the LCA if there is no face-to- face visit to the resident within 10 business days of the referral date.

52. 52 Task 6: Decision-Making Regarding MDS 3.0 F-172 Access to residents by any entity or individuals who provide health, social, legal, or other services Cite if the facility denies access to residents by the LCA or other community resources that are involved in the resident’s return to the community.

53. 53 Task 6: Decision-Making Regarding MDS 3.0 F-204 Sufficient preparation and orientation for safe & orderly discharge from the facility Cite if the discharge preparation did not include: Follow-up appointments with physicians if appropriate Community resources & DME equipment/supplies as needed Medication education with resident or support person Prevention & disease mgt. education Return demonstrations as needed Community mental health referrals as appropriate Warning symptoms & who to call in case of an emergency Any other related issues or referrals

54. 54 Task 6: Decision-Making Regarding MDS 3.0 F-250 Medically-related social services to attain or maintain highest practicable well-being Cite if medically related social services for discharge planning did not include resident responses to Section Q or if plans to return to the community were not coordinated with the LCA by the social worker/designee.

55. 55 Task 6: Decision-Making Regarding MDS 3.0 F-272 through F-278 - Comprehensive, accurate, timely assessment of the resident’s functional capacity Cite if the MDS 3.0 does not accurately or comprehensively reflect the resident’s functional status. Cite if the MDS 3.0 is not conducted according to required time frames.

56. 56 Task 6: Decision-Making Regarding MDS 3.0 F-279 Comprehensive plan of care Cite if the care plan does not include actions based on resident interview information from Section Q and other sections that have resident interviews (if appropriate). Cite if the care plan does not include discharge plans if the resident is returning to the community. Cite if the care plan does not include effective pain management. Cite if the care plan does not address other care issues identified in any section of the MDS 3.0.

57. 57 Task 6: Decision-Making Regarding MDS 3.0 F-280 Right to participate in planning care and treatment Cite if the resident was not involved in the MDS 3.0 sections that require resident interviews and the subsequent care planning process.

58. 58 Task 6: Decision-Making Regarding MDS 3.0 F-284 Discharge planning Cite if there is no coordination between the facility and the LCA (if a referral was made to the LCA). Cite if the discharge instructions and referrals to the community are not complete.

59. 59  Additional resource materials can be found online at: http://www.cms.gov/NursingHomeQualityI nits/25_NHQIMDS30.asp

60. 60  Questions?