Accuracy in Minimum Data Set (MDS) Assessments

Why it is imperative to financial and regulatory success to complete MDS assessments accurately

Nancy Day, RN, CRRN, CLNC

Tracy Kania, RN, BSN, CRRN

Since reimbursement and the Quality Indicators are based on Minimum Data Set (MDS) responses, it is imperative to financial and regulatory success to complete MDS assessments accurately. Inaccuracies not only can lead to financial devastation but also can impact quality care and services. Inaccurate MDS coding does result in Resident Assessment Protocols (RAPs) not being triggered appropriately, inaccurate case mix grouping, erroneous Quality Indicator Reports from the state database, unsuitable care plan needs and/or interventions being identified, and potentially negative outcomes.

Assessments are not valid if they do not reflect the clinical and functional status of the resident. Assessments are not reliable if different clinicians interpret MDS items in different ways. Care plans based on low-accuracy assessments are not likely to effectively address the needs of the resident. Facilities should be concerned about accuracy of MDS assessments and resulting RAPs.

The assessment coordinator is often the key person in assuring financial success resulting from Prospective Payment Systems. The roles and responsibilities of the assessment coordinator should be well-defined in facility policies and procedures.

According to HCFA guidelines, the RN coordinator is responsible for validating that the MDS is complete and the date it was completed. However, many facilities impose many additional responsibilities on the MDS coordinator, including accuracy of the entire MDS, documentation of all triggered RAPs, calculation of case mix, transmission of assessments, coordination of care plan completion, etc. Additionally, some facilities also require other supervisory or direct care responsibilities. The first step to financial success through the assessment coordinator is to re-evaluate his/her role and responsibilities and to assure there is proper time, training, and leadership skills to effectively complete the assigned tasks.

The next step to financial success is to recognize intricacies of the MDS.

When working with facilities with negative outcome surveys, denial of PPS claims, or default payments, many common pitfalls have been detected. Following are some common pitfalls and possible solutions:

Pitfall: Incomplete assessments. Blanks on the assessment will result in a "fatal" record during transmission to the state database. Consequently, delays occur and possibly could result in the facility receiving "default" rates on PPS assessments.

Blanks on the assessment force the already time-pressed coordinator to chase down other disciplines to complete their sections of the assessment. If this occurs frequently, tension and frustration between the disciplines can result.

Solution: The problem with blanks on the assessment has been greatly reduced with the implementation of automation; still, some software packages do not alert staff when blanks occur. The facility should screen software vendors for this essential design feature.

The RN coordinator should perform an examination of assessments prior to signing section R2b of the MDS. The intent of the examination is to identify any blanks on the assessment and to assure every section of the MDS is certified as accurate and complete with a signature and a date.

Pitfall: Missing signatures. Each section of the MDS must be certified as accurate.

Solution: As a Quality Assurance activity, an audit of MDSs can be performed to determine if blanks and missing signatures are a problem for the facility. This occurrence can be objectively calculated and reported to administration.

The facility can audit transmission validation reports from the state to quantify the number of "fatal" records. This objective data can be shared with administration.

Each discipline signing the MDS must fully understand the personal and professional implications of the MDS attestation statement enacted in September, 2000.

The RN coordinator should be reminded that the assessment cannot be signed off as complete on section R until each section of the MDS is completed.

Pitfall: Confusion with HCFA's definition of the assessment reference date (ARD).

Solution: Teach staff HCFA's definition of the assessment reference date. The ARD sets the designated endpoint of the common observation period, and all MDS items refer back in time from this point. Clinicians are to observe across all three shifts (24 hours per day) for the full observation period. For example, if the ARD is May 27, the period of common observation of seven-day items is May 21–27. For 14-day items, the common observation period is May 14–27, and so on.

Pitfall: Failure to set the appropriate assessment reference date. SNFs that fail to perform Medicare assessments in a timely manner are paid a default payment for the days of a patient's care for which they are not in compliance. Facilities that fail to follow OBRA requirements are subject to regulatory penalties.

Assessment coordinators should work closely with the therapist in deciding which day would be the most beneficial financially as well as promoting the best outcome for the resident.

Solution: The facility should be in compliance with setting assessment reference dates.

Medicare requirements. If the resident is a part A Medicare beneficiary, the ARD must fall within very specific timeframes.

OBRA requirements. If the resident is not covered by Medicare A, to fulfill OBRA requirements, the ARD can be any date from admission until the 14th day following admission. When the admission date is used as the ARD, the assessment is based on information from an observation period that precedes the resident's stay (e.g., hospital records).

Pitfall: Assessments not completed on time. SNFs that fail to perform Medicare assessments in a timely manner are paid a default payment for the days of a patient's care for which they are not in compliance. Facilities that fail to complete OBRA required assessment on time are subject to regulatory penalties.

Solution: Medicare requirements. For Medicare payment, it is required that any assessment be completed within 14 days of the ARD. However, the clinician must also meet OBRA requirements.

OBRA requirements. The facility must conduct a comprehensive assessment of a resident within 14 days after admission, within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, and not less than once every 12 months.

A facility must perform a quarterly review assessment not less frequently than once every three months.

The facility can establish an organized schedule for assessments and care planning. The schedule can be shared with each member of the interdisciplinary team and the staff nurses. The schedule can include information, such as the resident's name, type of assessment due, assessment reference date, date due to be completed, and care plan conference date.

Once the schedule is established, administration can easily monitor the facility's adherence to the schedule.

Pitfall: Failure of the clinician to take information from the medical record covering the same observation period as specified by the MDS items.

Solution: While auditing the MDS, the facility can examine the medical record to assure that information taken from the medical record covers the same observation period as that specified by the MDS items (e.g., 7 day, 14 day, 30 day, etc.). The medical record should support MDS responses.

Pitfall: Failure to communicate with and observe the resident.

Solution: While auditing the MDS, the auditor should spend time with the resident communicating with and observing the resident function in his/her environment. The responses should closely mirror the auditor's assessment, unless the resident has experienced a significant change in status.

If differences are noted, an explanation should be documented. Where documentation is lacking or missing, it should be added to the medical record.

Pitfall: Attempting to complete the assessment without fully understanding HCFA's definition of MDS items.

Solution: Initially, the facility needs to assure that the assessment coordinator has access to the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual.¹

Additionally, the facility can offer education to the interdisciplinary team and staff members. Training should focus special attention on Chapter 3 of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual.¹ This chapter provides HCFA's definition and procedural instructions necessary for accurate assessment.

Pitfall: Failure to realize that the MDS is a functional assessment. Functional status differs from medical or clinical status in that the whole person's life is reviewed with the intent of assisting that person to function at his or her highest practicable level of well being.

Solution: The resident should be assessed with any assistive or functional devices in place. For example, if the resident wears glasses, these should be in place prior to completing section D of the MDS.

Pitfall: Not clarifying information in the medical record that is inconsistent with verbal information or physical assessment findings. For example, the medical record states that the resident is continent of bladder. Upon interviewing the resident in her room, pads were observed. The resident states, "Oh, yes, I have accidents at night when I can't get to the bathroom in time."

Solution: The facility can initiate processes for the interdisciplinary team to follow when discrepancies are noted:

* Discuss discrepancies with other interdisciplinary team members (e.g., nurses, social workers, therapist).

* Clarify and validate all such information during the assessment process.

* Make clarification notes in the medical record, if necessary.

Pitfall: Staff might not think to report/record behaviors/mood if it is part of the normal routine. For example, on an Alzheimer's unit, staff may not think to document that the resident is resisting care because the documentation design for the facility is to chart by exception.

Solution: Clinicians must realize that "documentation in the clinical record of the resident's current status may not be accurate or valid, and it is not intended to be the one and only source of information."¹

The clinician must develop interviewing techniques to elicit accurate responses from the staff. For example, effective questions could be:

* Have you seen any signs of crying or depression in Mr. X within the last 30 days?

* Does Mrs. Y ever physically or verbally abuse staff or other residents?

Pitfall: Using the medical record as the only source of information.

Solution: The interdisciplinary team must remember that the resident is the primary source of information.

The facility may wish to provide a worksheet that staff (e.g., CNAs) could use to note particular resident information (e.g., ADLs).

Pitfall: Documentation in the medical record does not support MDS responses.

Solution: Once a schedule for MDSs is established, this can be shared with the direct care staff. The facility consultant can be instrumental in setting up systems to focus staff on MDS items while documenting during the assessment period.

During completion of the MDS, the Interdisciplinary Team should communicate with direct care staff from all shifts.

Pitfall: Not identifying significant changes in a timely manner.

Solution: The facility must create effective systems for identification of significant change in status within the facility. Some facilities have even trained the direct care in the criteria for significant change.

Pitfall: Direct care staff may hesitate to respond to MDS items. Often direct care staff misinterpret the purpose of the clinician's assessment questions. For example, the clinician may say, "Describe how Mrs. L transfers herself." The CNA may be reluctant to report that she asks for assistance when all the other CNAs are able to transfer Mrs. L without additional assistance.

Solution: Staff should be reassured regarding what the purpose of the RAI process is and that it is not an evaluation of their job performance.

The clinician is obliged to measure what the resident actually did during the observation period, not what he or she might be capable of doing.

Pitfall: Failure of staff to understand the impact of MDS responses on the case mix.

Solution: Staff should be informed of MDS items that affect case mix. "Undercoding" a resident's functional abilities will result in the facility receiving less reimbursement than deserved.

Pitfall: Failure to transmit assessments punctually. Bills only may be sent for assessments that have been accepted at the state database.

Solution: In some cases, the facility needs to complete and transmit more quickly in order for the facility to be ready for the facility monthly billing date.

Conclusion

Completing the MDS accurately and in a timely fashion needs to be the fundamental goal of the assessment coordinator. As many facility members as possible--such as nursing supervisors, quality assurance officers, directors of nursing, and administrators--must be involved in identifying pitfalls within the facility and implementing a quality improvement action plan. If this is accomplished, not only will the facility realize financial success, the resident will receive outstanding care and services.

References

1. Morris JN, Murphy K, Nonemaker S. Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual. Health Care Financing Administration, October 1995.

Ms. Day is the president and Ms. Kania is the vice president of clinical services at New Day Professional Services. New Day Professional Services provides education and consultation to long-term care facilities and organizations nationally. For more information, call (803) 796-7835.