Long-Term Care Survey Alert

If nursing facilities are most concerned about the havoc that the upcoming national quality initiative may wreak on their survey records, they haven't met DAVE.

The Centers for Medicare & Medicaid Services' new Data Assessment and Verification initiative (aka DAVE), which is ramping up in 2003, will use protocols to identify MDS coding errors that compromise resident care and payment integrity. CMS is currently testing DAVE in a sample of facilities in Indiana and Georgia (see p. 68). Once the beta testing is completed at year's end, CMS plans to implement DAVE nationwide by adding states incrementally.

With DAVE coming in the near future, nursing facility providers have wondered how the project will interface with the survey process, both as a pilot and national initiative, reports Rena Shephard, a member of the CMS stakeholder group for the DAVE project and president of the American Association of Nurse Assessment Coordinators. "The answer is that DAVE reviewers are not going to ignore situations where MDS inaccuracy might indicate that resident care has been compromised. In such a case, the DAVE contractor will report the findings to the state agency for further investigation or action," she tells Eli.

"When one considers that the MDS was originally developed as a clinical tool to improve resident care by improving care planning, it follows that if the MDS is inaccurate, the care plan may not have met resident needs," Shephard adds. "So that's the connection to the survey process."

The MDS is also a payment tool, so the DAVE contractor will report inappropriate Medicare payments to the fiscal intermediary.

Yet CMS has promised long-term care groups that DAVE is not using a "gotcha approach," reports Ruta Kadonoff, health policy analyst for the American Association of Homes & Services for the Aging. "CMS has emphasized that the big picture is focused on improving data quality overall over time."

The DAVE process begins with "extensive analyses of MDS assessment and Medicare claims data to identify national, state and provider patterns and trends," according to Steve Pelovitz, director of CMS' Survey and Certification Group, in a recent letter to stakeholders in the DAVE process. The analyses are designed to flag "situations that require further investigation through medical record review or provider site visits."

Last month, DAVE clinicians commenced onsite reviews at a handful of nursing facilities in the two test states. As part of the onsite review, the DAVE reviewers compare residents' MDS assessments to corresponding medical records and care plans and the residents themselves. The onsite review is not limited to Medicare residents, according to Kadonoff.

"It's safe to assume that reviewers will target MDS items that trigger quality indicators and the resident assessment protocols, as these impact care planning," she adds.

The onsite reviews include a "reconciliation process" where DAVE reviewers talk to facility staff to try to figure out why certain MDS records don't jibe with their onsite chart reviews and resident assessments. "For example, perhaps the MDS was accurate at the time it was done and the resident's condition has since changed," Kadonoff explains. "Or there may be a misunderstanding about coding criteria."

Providers will receive reports outlining the results of their medical record review or onsite visit, CMS says. In addition to the provider reports, CMS plans to implement national and state educational efforts designed to improve MDS accuracy.

According to Kadonoff, CMS intends facilities to use the DAVE-generated reports to perform their own self-audits or reviews.

"The reports will identify consecutive MDSs where one would have expected either change or no change to have occurred for example, a resident who has a urinary tract infection coded on two consecutive 90-day assessments," Kadonoff explains.

The DAVE reports, expected to go to facilities in the test states this fall, will also include guidance to help facilities interpret the MDS reviews and make needed quality improvements. "For example, using the UTI example, the report may suggest that facilities check to see if an automatic computerized program could have duplicated the same information from one assessment to the next," Kadonoff explains.

The American Health Care Association says it has a number of issues with the DAVE beta test that the organization wants resolved before national rollout of the initiative. These include: