MDS Alert

Published on Fri Jul 18, 2008 PDF

If you're not doing this, your facility is wide open for survey woes.

When surveyors have questions about MDS coding, care planning or quality indicators/measures, whom are they likely to ask? You guessed it -- and the best motto for you or the person in this position is "be prepared." Indeed, the MDS coordinator can play a pivotal primetime and behind-the-scenes survey management role. Here's how:

1. Troubleshoot MDS areas you know are a survey focus. For example, surveyors are targeting restorative nursing coded in Section P3 to make sure it meets the RAI manual requirements and that a nurse has done a baseline assessment of the resident receiving restorative, says Dee Kostolich, RN, a consultant with Howard Wershbale and Co. in Cleveland. And the MDS nurse is in a perfect position to review the restorative program to make sure everything is in order.

Kostolich also finds that surveyors are looking at how medications are coded in Section O4, which should be based on the medication's classification rather than the intended therapeutic effects.

Proactive survey strategy: The MDS nurse should make sure to code medications correctly in O4 and confirm that the medical record contains documentation to support the reason for using a medication coded in O4.

Cautionary survey example: Surveyors cited one facility because the physician had ordered trazodone for insomnia for a patient who was also receiving an antidepressant for depression. "Since the medical record and care plan did not include a clarification that the medication was prescribed for sleep, the surveyors concluded that the facility was double-dosing the resident," Kostolich says.

2. Aim for coding confidence and speedy corrections. MDS nurse Holly Sox, RN, in Lexington, SC, finds that if surveyors have a coding concern, and the MDS nurse provides her rationale for coding based on the RAI manual and clinical judgment, surveyors tend not to cite the nursing facility.

On the other hand: If the MDS contains significant errors, that's "fair game" for F tags, adds Sox. "In those cases, it's best to go ahead and do the modification and changes to the care plan, if needed, while surveyors are still there, if possible. Taking action quickly shows the surveyors you know what to do if there is an error." Sox saw one situation where the MDS nurse didn't make a correction during the survey, leading surveyors to dig deeper into the facility's RAI process.

3. Support staff doing MDS documentation during the assessment window. "Take action to ensure accurate documentation" during the MDS lookback period, advises Cheryl Boldt, RN, a consultant with Maun Lemke in Omaha, NE. "We encourage MDS nurses and other MDS process owners to be out with the frontline team, coaching and reviewing documentation with them during the assessment window," says Boldt. The staff responsible for completing various MDS sections can act as "cheerleaders for staff to capture the level of care provided related to the resident's condition during this time." By using that strategy, reconciliation charting should not be needed very often, Boldt adds.

4. Help keep the care plan process on track to reflect a resident's real-time needs. If surveyors find that the MDS assessment, care plan and care provided don't jibe, watch out. In such a case, the facility may receive multiple deficiencies for the same issue, cautions nurse attorney Barbara Miltenberger, with the law firm of Husch Blackwell Sanders LLP in Jefferson City, MO.

Example: Sometimes the MDS nurse or team will put an intervention in the care plan but does not let staff know about it right away. "This is particularly true with falls. If the care plan says one thing and the care being given is different, surveyors often find fault with the care plan process," Miltenberger says. And if the resident falls again and gets injured, surveyors will likely find actual harm, she adds.

Tip: The MDS nurse can help the team ensure the care plan is updated and the frontline staff complies with the interventions. "Using a pocket-guide is one way to do that," Boldt notes (for details, see "Help Caregivers Pocket What They Need To Improve Care, Quality Of Life," and a copy of a pocket-guide format in the Volume 5/No. 7 MDS Alert in the Online Subscription System archives).

During the survey, the MDS coordinator should be prepared to give surveyors information about current assessments and care plans, says Marty Pachciarz, RN, RAC-CT, a consultant with Pathway Health Services in Beaverton, OR. "The RAP summary notes can be key to pulling together the resident care needs and risk factors that impact care planning," she adds.

5. Help the team target QIs/QMs before the survey. The MDS nurse should be part of the QA team that reviews QI/QM reports and identifies residents and areas likely to be a survey focus, suggests Pachciarz. The MDS nurse can also help to determine if a high or rising QI/QM is due to MDS coding issues as opposed to a clinical care shortfall or a change in patient case-mix, as examples.

Preempt the reports: The MDS nurse may be able to identify trends even earlier than the QI/QM reports because she does the MDSs before they are transmitted to the state, says Elizabeth Brunner, RN, NHA, a consultant with Pathway Health Services. "The MDS nurse may see a cluster of certain types of behaviors, for example, that other interdisciplinary team members haven't noticed, even though they are providing the information for Section E4."