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

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MDS 3.0 – Changes in MDS 3.0 – Changes in the Survey Processthe Survey Process

ByByHaideh Najafi, RN, BSN, MSED, EDSHaideh Najafi, RN, BSN, MSED, EDS

And Tedi Beckett, RN, MSNAnd Tedi Beckett, RN, MSNSeptember 15, 2010September 15, 2010

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ObjectivesObjectives 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.

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Important!Important!

• MDS 3.0 will replace MDS 2.0 on Oct 1, 2010.

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Goals of the MDS 3.0Goals 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.

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Goals of the MDS 3.0 Goals of the MDS 3.0 (continued)(continued)

Increase the reliability, efficiency, and usefulness of the MDS.

Use standard protocols used in other settings.

Improve clinical assessment.

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MDS 3.0MDS 3.0

RAI

MDS CAA (RAPs) Utilization guidelines

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Purpose of Purpose of thethe CAA Process CAA Process

• Identify potential resident conditions and issues.

• Identify risks and causes of resident conditions.

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Comparison of Comparison of MDS 2.0 & 3.0MDS 2.0 & 3.0

MDS 2.0 MDS 3.0

RAP CAA

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.”

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Changes in Selected MDS Changes in Selected MDS SectionsSections

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

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Comparison of MDS 2.0 & 3.0Comparison of MDS 2.0 & 3.0Section J – Health ConditionsSection 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.

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MDS 3.0 - Section JMDS 3.0 - Section JHealth Conditions (continued) 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.

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Comparison of MDS 2.0 & 3.0Comparison of MDS 2.0 & 3.0Section M: Skin ConditionsSection M: Skin Conditions

MDS 2.0 MDS 3.0

Does not include

this information.

Determination of Pressure Ulcer Risk

Does not include

this information.

Unhealed pressure ulcer

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Comparison of MDS 2.0 & 3.0Comparison of MDS 2.0 & 3.0Section M (continued)Section M (continued)

MDS 2.0 MDS 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

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MDS 2.0 MDS 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

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MDS 2.0 MDS 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

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MDS 2.0 MDS 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

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Reverse staging/backstagingReverse staging/backstaging

Current clinical standards do notsupport reverse staging or backstaging.

Past Now

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.

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Comparison of MDS 2.0 & 3.0Comparison of MDS 2.0 & 3.0Section O: Special Treatments, Section O: Special Treatments,

Procedures, and ProgramsProcedures, and Programs MDS 2.0 MDS 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

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Comparison of MDS 2.0 & 3.0Comparison of MDS 2.0 & 3.0Section O (continued)Section O (continued)

MDS 2.0 MDS 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.

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Section P: RestraintsSection 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.

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Section Q: Return to the Section Q: Return to the CommunityCommunity

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.

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Section Q (continued)Section Q (continued)

MDS 2.0 MDS 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).

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Section Q (continued)Section Q (continued)MDS 2.0 MDS 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

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How does MDS 3.0 affect the How does MDS 3.0 affect the survey process?survey process?

There will be changes in: a) Sample selection. b) Validating interviews. c) Care Area Assessment (CAA)

process. d) The tasks & the SOM.

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Important!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).

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How will this affect the How will this affect the survey process?survey process?

The survey process will go back to the 1995 survey procedures until QI/QM data become available.

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Are the CMS forms changing?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)

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Revisions to the Instructions for Revisions to the Instructions for the Roster/Sample Matrixthe 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).

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Revisions to the Revisions to the Roster/Sample MatrixRoster/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.

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Are the survey

tasks changing?

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Task 1: Off-site PrepTask 1: Off-site Prep

Teams will not be able to generate an off-site sample based on the QI’s during this interim period.

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Task 1: Off-site Prep (Continued)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.

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Task 1: Off-site Prep (Continued)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)

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Task 2: Entrance ConferenceTask 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.

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Task 2: Entrance Conference Task 2: Entrance Conference (Continued)(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.

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Task 3: Initial TourTask 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).

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Task 3: Initial Tour (Continued)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.

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Task 3: Initial Tour (Continued)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

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Task 4: Sample SelectionTask 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.

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Task 4: Sample Selection Task 4: Sample Selection (Continued)(Continued)

Sample selection should be case mix stratified to capture:

• Interviewable residents.

• Non-interviewable residents.

• Residents receiving heavy care.

• Residents receiving light care.

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• Various stages of impairment of:

1) Physical dependency.

2) Functional dependency.

3) Cognitive functioning.

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WHP sample selection:

• Weight loss.

• Hydration risk.

• Pressure ulcer.

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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

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Task 5: Information Gathering -Task 5: Information Gathering -CAA ProcessCAA Process

Verify that information obtained and recorded during the structured interviews on the MDS 3.0 is accurate and correct.

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Resident interview sectionsResident 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.

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Task 5: Information Gathering -Task 5: Information Gathering -CAA Process (Continued)CAA Process (Continued)

Review Care Area Triggers (CAT’s). All CAT’s do not necessarily require care planning.

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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.

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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.

4949


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.”

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Look for evidence that the information from the resident’s interviews has been incorporated into a care plan (especially from section Q).

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Task 6: Decision-Making Task 6: Decision-Making Regarding MDS 3.0Regarding 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.

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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.

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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

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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.

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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.

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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.

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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.

5858


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.

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Additional resource materials can be found online at:

http://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp

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Questions?

Documents

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