FAQs - Long Term Care
OVERVIEW GUIDE - MDS 3.0
To remain in compliance with the Level II Pre-Admission
Screening and Resident Review (PASRR), what is the correct
procedure when I need to complete a significant change status
minimum data set (MDS)?
Notify the Bureau of Developmental Disabilities Services (BDDS)
for mentally retarded/developmentally disabled/mentally ill
(MR/DD/MI) residents. Also, when the significant change has an
impact on the resident's mental health, notify a community mental
health center (CMHC).
Example: A long-term nursing facility (NF)
resident with a Level II, which indicates the resident is mentally
ill (MI), falls and breaks a hip. A significant change may be
needed; however, the resident needs referral to the mental health
authority only if the mental health of the resident is affected by
this physical condition change.
Is it true that we no longer have to keep a hard copy of the
MDS on the resident's chart?
This is correct. Per the Centers for Medicare & Medicaid
Services (CMS), due to the hardship placed on facilities to
maintain paper copies, making electronic copies available to
regulatory entities is sufficient.
Will HP look at the MDS on the computer?
Whatever form is maintained by the facility (for example, paper
or electronic) will be reviewed to audit/validate records.
COGNITIVE PATTERNS SECTION - MDS 3.0
A cognitive intact diabetic resident continues to eat candy. Is
this a poor decision?
Per State Resident Assessment Instrument (RAI) Coordinator
Barbara Wheeler, R.N., in the RAI Manual, p. C-24: "A
resident's considered decision to exercise their right to decline
treatment or recommendations by the interdisciplinary team members
should NOT be captured as impaired decision making in item C1000."
"Cognitive Skills for Daily Decision Making"
We have behavior/psych residents who memorize the three words
for short-term memory (STM) after using the same words over and
over, but with first-time use, cannot recall all three words after
five minutes. How can we substantiate poor short-term memory if we
have to use the same words over and over on the MDS 3.0?
The CMS made the determination to use the same words repeatedly.
Hence, facilities must continue to use the CMS guidelines
(including the use of the three consistent words). Facilities may
use ancillary tools/assessment of cognitive ability at their
discretion. However, coding of the MDS must be made according to
the instructions provided by the RAI Manual.
MOOD SECTION - MDS 3.0
Staff Assessment of Resident Mood (PHQ-9-OV) - If staff is
interviewed to answer the mood questions and determine the
frequency with which they occur, will documentation of that
information by the interviewer be enough to support? Or does there
need to be additional documentation in the clinical record in the
past 14 days?
There must be documented examples demonstrating the presence and
frequency of clinical mood indicators, as reported by staff, during
the observation period. In short, what evidence is there for staff
to report the mood indicators and frequency?
Do you need any supportive documentation for an interview
(D0200A-I) and when it was done?
A: The MDS, with completed Z0400, is considered
the source document for the PHQ-9.
FUNCTIONAL STATUS SECTION - MDS 3.0
Does the key for self-performance and support provided have to
be visible on the printed activities for daily living (ADL)
grid?
The ADL grid is an optional tool. If used, the key must be
within the line of sight of the person coding the values and
available when requested. It is not mandatory that the key be
printed on the ADL grid itself. If there is no key, the ADL values
will be considered unsupported for the review.
Do we have to have 21 entries on the ADL grid?
The ADL grid is representative of the care provided during the
observation period. Again, the ADL grid is an optional tool, as
providers may choose to represent this information in whatever
fashion or format the provider chooses.
The number of potential entries on the grid is adapted to the
shifts and schedules specific to the facility. For example,
potential entries for a facility working 12-hour shifts would be
fewer than those for a facility working eight-hour shifts. The
number of entries would be commensurate with the number of days in
the applicable observation period.
How do I make corrections on the ADL grid?
One line should be placed through the incorrect information. In
addition, the staff's initials, the date the correction was made,
and the correct information should be entered, or the location of
the correction denoted (for example,"see nurse's note
dated.....").
If the resident is on leave of absence (LOA), how is it tracked
and applied to the ADL grid?
The ADL grid is optional. A facility may instruct staff to make
a notation on the grid that the resident was "LOA" on applicable
shifts/dates, or may instruct staff to code the activity as an "8"
(activity did not occur).
Our computer program allows us to remove specific items from
the certified nurse's assistant (CNA) view. We have a secured unit
where dementia residents cannot leave independently. Can we remove
"independently" from the CNA view for "locomotion off unit" and
still validate?
This is not a Resource Utilization Group (RUG) item. Any
revision to the software/program used by the facility is at the
facility's discretion.
Does an ADL score of 7 throw out coma?
There is no score related to coma. An ADL coding value of 7 will
not support the coma string.
ACTIVE DIAGNOSIS SECTION - MDS 3.0
Define "active diagnosis in the past 7 days." What
documentation is required to support a diagnosis of cerebral palsy,
a coma diagnosis, or a diagnosis of quadriplegia?
Per the RAI Manual, an active diagnosis is one that has
a direct relationship to the resident's functional status,
cognitive status, mood or behavior, medical treatments, nursing
monitoring, or risk of death during the observation period (that
is, the look-back period). Receiving medications for treatment of
diagnosis during the observation period could indicate that the
diagnosis is active, as the resident is receiving medical
treatment.
Once a diagnosis is identified (per physician-documented
diagnosis in the last 60 days), it must be determined whether the
diagnosis is "active." Conditions that have been resolved or no
longer affect the resident's functioning or plan of care during the
observation period are not considered "active."
Can you please clarify what is meant by a diabetic string -
does this involve N0350B?
The diabetic string includes I2900 (Diabetes Mellitus); NO300
(injections = 7 days); and O0700 (physician order changes = 2 or
more). It does not include N0350B.
SKIN CONDITIONS SECTION - MDS 3.0
How do auditors look at a list of Stage III or
Stage IV ulcers when there is no reverse staging?
Auditors will no longer review all Stage III and Stage IV
ulcers. An auditor may ask to review a specific ulcer to validate a
record. If so, it may be necessary for the facility to retrieve and
supply documentation dating to the origin of the stage which
supports the present coding of the ulcer (at its worst) if the
status of the ulcer has changed.
Since pressure ulcers (MO300) are no longer down-staged (they
are now coded as the worst they ever were), why is HP requiring a
stage, measurements, and description during the observation period?
Shouldn't documentation of the ulcer and worst stage be
sufficient?
HP no longer requires a list of Stage III and Stage IV ulcers
with stage, measurements, and description during the observation
period. An auditor may ask to review a specific ulcer in an effort
to validate a record. If so, it may be necessary for the facility
to retrieve and supply documentation dating to the origin of the
stage which supports the present coding of the ulcer (at its worst)
if the status of the ulcer has changed.
Should items such as w/c cushions, mattresses, and so forth, on
the care plan for long-term use not be counted unless they are
mentioned elsewhere during the observation period? Is the care plan
part of the medical record if it is in place during the observation
window?
The care plan is a component of the medical record; however, the
care plan may not have been reviewed within the observation period.
Documentation at least once within the observation period (whether
via CNA care documentation, treatment administration, and so forth,
which remains part of the medical record) is to affirm that the
coded devices were in use during the observation period.
SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS SECTION -
MDS 3.0
Is restorative dressing a separate program from restorative
grooming? Can we count minutes only from one program or the other
on any MDS? For example, can a 10-minute dressing and 10-minute
grooming be added together?
Under O0500H, the RAI Manual defines "dressing and/or
grooming" as one program. Hence, it can be either, or it can be
combined, but remains one program. The activities are
individualized to the resident's needs, planned, monitored,
evaluated, and documented in the resident's medical record. In
short, what you are coding should be reflective of what you are
doing - dressing only, grooming only, or a combined
dressing/grooming restorative program.
I make a monthly note on every restorative program and cosign
the restorative aide's note. Do I have to continue to make a
monthly note, or can I just cosign the restorative aide's note
during the observation period?
A progress note written by a restorative aide and cosigned by a
licensed nurse during the observation period meets the requirement
of a periodic evaluation once the program has been established.
Can you please clarify what is meant by a "periodic evaluation
by a licensed nurse" with regard to restorative nursing care? The
Supportive Documentation Guidelines refer to "documentation during
the observation period."
As the coding of the MDS reflects the status of the resident
during the assessment reference/observation period, an evaluation
is appropriate if completed during the observation period.
There is no option for "start of therapy" or "end of therapy"
for non-Medicare residents. Where do we code those options?
There is no Medicaid requirement for start or end of
therapy.
If you have a new diagnosis by telephone order - for example,
Lasix for hypertension - but it is new and not yet signed by the
physician, is it considered a physician's order?
A "telephone order" is acceptable per the RAI Manual.
The regulation requires that the physician sign the order on his or
her next required visit; however, this does not negate the need to
initiate the order. Thus, the order is an active order once it is
received.
A pharmacy sends a recommendation to interchange a medication -
for example, Protonix interchange with Prilosec. We ask if the
doctor agrees, and the doctor signs "yes." Is that considered a
physician's order?
An order received to initiate a new or different medication is a
new physician's order.
Nursing Facility admissions and Care Select
What is the nursing facility admission process for Care
Select members?
Nursing home admissions for Care Select members follow
the same admission process as for the traditional Fee-for-Service
(FFS) Medicaid population. Members who are assigned to a primary
medical provider (PMP) in the Care Select delivery system
are disenrolled from the managed care program when LTC level of
care is approved and entered into IndianaAIM. The PMP is
not responsible for certification of nursing facility services.
Q&As from Myers & Stauffer MDS training - October
13, 2011