MDS Alert

Published on Thu Oct 01, 2009 PDF

Use this key litmus test to see if you're in compliance.

Providing good skin and wound care for a resident on hospice is one thing, but you have to be able to show surveyors and other auditors that you did.

Start by keeping the nursing home and hospice plans of care in lockstep. A mismatch between the plans could get the F tags flying (or the L tags for hospice).

Must do: "The Conditions of Participation for both SNFs and hospices require that the care plans for  both providers "correspond to each other," says Harold Bob, MD, CMD, a medical director for nursing homes and hospices in Baltimore, Md.

The care plan should reflect the patient's and family's input and goals. And the record should show evidence that the nursing facility and hospice providers discussed the plan with the patient's routine healthcare providers, adds Bob.

Spotty physician documentation can leave the facility in the lurch come survey time. For example, the physician notes should spell out the rationale for the care plan and expected outcomes.

Example: The progress note for a patient near end of life might read: "Skin extremely fragile, and due to cachexia of terminal illness, breakdown is expected and non-preventable," suggests Bob.

"Good physician notes show that the nurse notified the physician of any changes in risk factors for skin breakdown or that the resident has developed a pressure ulcer," says Jennifer Gross, RN, BSN, a consultant with PointRight Inc. in Lexington, Mass. That kind of documentation is "an indicator that the whole team, including the physician, is working together to take care of the resident."

Check at P1ao that the resident is on hospice, and at J5c to indicate that he has end-stage disease. Coding the latter requires a physician note in the clinical record stating that the person has a prognosis of six months or fewer to live, reminds Gross.

Section M5 should include everything the facility is doing for wound prevention or treatment. "For example, the facility may be using pressure-relieving devices, such as a special bed, to promote comfort and prevent skin breakdown," Gross notes.

The MDS should also definitely capture any advance directives -- for example, a DNR or do not hospitalize order, advises Gross. Also code feeding restrictions, which would include no artificial nutrition and hydration (IV fluids or tube feeding), she adds.

Watch out: Although nutrition and hydration are "huge preventive measures" for pressure ulcers, they "may be contraindicated in a palliative care plan" based on an advance directive or the resident/family's wishes, etc., Gross cautions.