mds 3.0 changes effective 10/1/17 10/11/2017 mix/mds changes oct 201… · mds 3.0 changes...

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10/11/2017MDS 3.0 Changes Effective 10/1/17

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Facilities must have written policies in place to ensure proper security measures are inplace to protect the use of an electronic signature by anyone other than the person towhom the electronic signature belongs.

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Nursing homes must also ensure that clinical records, regardless of form, are easily andreadily accessible to staff (including consultants), State agencies (including surveyors),CMS, and others who are authorized by law and need to review the information in order toprovide care to the resident. Resident specific information must also be available to theindividual resident.

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All State licensure and State practice regulations continue to apply to Medicare and/orMedicaid certified long-term care facilities. Where State law is more restrictive thanFederal requirements, the provider needs to apply the State law standard.

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It can be performed at any time after the completion of an Admission assessment, and itscompletion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s determinationwas made that the resident had a significant change.

Please note: A significant change may require referral for a Preadmission Screening andResident Review (PASRR) evaluation if a mental illness, intellectual disability (ID), or otherrelated condition is present or suspected to be present.

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Decline in two or more of the following:Resident’s decision-making ability has changed;

Presence of a resident mood item not previously reported by the resident or staff and/oran increase in the symptom frequency (PHQ-9 ), e.g., increase in the number of areaswhere behavioral symptoms are coded as being present and/or the frequency of asymptom increases for items in Section E (Behavior);

Changes in frequency or severity of behavioral symptoms of dementia that indicateprogression of the disease process since the last assessment;

Any decline in an ADL physical functioning area (at least 1) where a resident is newlycoded as Extensive assistance, Total dependence, or Activity did not occur since lastassessment and does not reflect normal fluctuations in that individual’s functioning;

Resident’s incontinence pattern changes or there was placement of an indwellingcatheter;

Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in180 days);

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Emergence of a new pressure ulcer at Stage 2II or higher, a new unstageable pressureulcer/injury, a new deep tissue injury or worsening in pressure ulcer status;

Resident begins to use a restraint of any type when it was not used before; and/or

Emergence of a condition/disease in which a resident is judged to be unstable.

MDS 3.0 Changes Effective 10/1/17 10/11/2017

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Improvement in two or more of the following:

Any improvement in an ADL physical functioning area (at least 1) where a resident isnewly coded as Independent, Supervision, or Limited assistance since last assessment anddoes not reflect normal fluctuations in that individual’s functioning;

Decrease in the number of areas where Behavioral symptoms are coded as beingpresent and/or the frequency of a symptom decreases;

Resident’s decision making improves;

Resident’s incontinence pattern improves.

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RAI page 2-32: While the CAA process is not required with a non-comprehensiveassessment (Quarterly, SCQA), nursing homes are still required to review the informationfrom these assessments, and review and revise the resident’s care plan

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However, the resident’s care plan must be reviewed after each assessment, as requiredby §483.20, except discharge assessments, and revised based on changing goals,preferences and needs of the resident and in response to current interventions.

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A1500: clarification: All individuals who are admitted to a Medicaid certified nursingfacility, regardless of the individual’s payment source, must have a Level I PASRRcompleted to screen for possible mental illness (MI), intellectual disability (ID), (“mentalretardation” (MR) in federal regulation)/developmental disability (DD), or relatedconditions.

In Maine, PASRR is required even if resident will be in the facility less than 30 days.

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This is not a change, but has now been added to the manual.

Page A-35: A03010H: Even though only an OBRA Discharge was required, when the Dateof the End of the Medicare Stay is on the day of or one day before the Date of Discharge,MDS specifications require that A0310H be coded as 1.

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No changes for Sections B, C, D, E, and F. Revision of the ADL algorithm in Section G.

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The Rule of 3• The “Rule of 3” is a method that was developed to help determine the appropriate codeto document ADL Self-Performance on the MDS.

• It is very important that staff who complete this section fully understand the componentsof each ADL, the ADL Self-Performance coding level definitions, and the Rule of 3.

• In order to properly apply the Rule of 3, the facility must first note which ADL activitiesoccurred, how many times each ADL activity occurred, what type and what level ofsupport was required for each ADL activity over the entire 7-day look-back period.

• The following ADL Self-Performance coding levels are exceptions to the Rule of 3:— Code 0, Independent – Coded only if the resident completed the ADL activity with nohelp or oversight every time the ADL activity occurred during the 7-day lookback periodand the activity occurred at least three times.— Code 4, Total dependence – Coded only if the resident required full staff performance ofthe ADL activity every time the ADL activity occurred during the 7-day look-back period andthe activity occurred three or more times.— Code 7, Activity occurred only once or twice – Coded if the ADL activity occurred fewerthan three times in the 7-day look back period. (This other occurrences would have been

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coded as 8)— Code 8, Activity did not occur – Coded only if the ADL activity did not occur or familyand/or non-facility staff provided care 100% of the time for that activity over the entire 7-daylook-back period.


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2. When an activity occurs 3 or more times at multiple levels, code the most dependentlevel that occurs 3 or more times.

3. Emphasis on not 3 times at any one level and This 3rd rule only applies if there areNOT ANY LEVELS that are 3 or more episodes at any one level. DO NOT proceed to 3a,3b, or 3c unless this criteria is met.

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Still does not specifically address the issue of 4s and 8s, but if you follow the rule of 3s andthe algorithm, that scenario would have to be coded as 3 (extensive)

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Do NOT record the type and level of assistance that the resident “should” be receivingaccording to the written plan of care. The level of assistance actually provided might bevery different from what is indicated in the plan.Record what actually happened.

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Review with CNA staff to ensure accurate coding of ADL on daily flowsheets

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No new GG items this year, but clarification of wording in the manual for that section. Notnew information, but it has now been added to the manual.

For Section GG, the admission assessment period is the first three days of the Part A staystarting with the date in A2400B, which is the Start of most recent Medicare stay.

On admission, these items are completed only when A0310B = 01 (5-Day PPS assessment).

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based on a clinical assessment that occurs soon after the resident’s admission.

If the resident performs the activity more than once during the assessment period and theresident’s performance varies, coding in Section GG should be based on the resident’s“usual performance,”

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Same coding convention.

Was the activity not attempted? Indicate why.

–Code 07, Resident refused, if the resident refused to complete the activity.–Code 09, Not applicable, if the resident did not perform this activity prior to the currentillness, exacerbation, or injury.–Code 88, Not attempted due to medical condition or safety concerns, if the activity wasnot attempted due to medical condition or safety concerns.

Clinicians may code the eating item using the appropriate response codes if the residenteats using his/her hands rather than using utensils (e.g., can feed himself/herself usingfinger foods). If the resident eats finger foods with his/herhands independently, for example, the resident would be coded as 06, Independent. (RAI,page GG-6)

Reminder: use the codes if an activity was not attempted, rather than using a “dash” whichmeans “no information”.

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RAI pages GG-6 and GG-23

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Admission assessment for wheelchair items should be coded for residents who used awheelchair prior to admission or are anticipated to use a wheelchair during the stay, even ifthe resident is anticipated to ambulate during the stay or by discharge.

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Updated link on Page I-4 for coding guidance with the use of Z codes. When Z codes areused,another diagnosis for the related primary medical condition should be checked in itemsI0100–I7900 or entered in I8000. ICD-10-CM coding guidance with links to appendices canbe found here:https://www.cms.gov/Medicare/Coding/ICD10/index.html.

RAI, page 3-3: With the exception of certain items (e.g., some items in Sections K and O),the look-back period does not extend into the preadmission period unless the iteminstructions state otherwise. In the case of reentry, the look-back period does not extendinto time prior to the reentry, unless instructions state otherwise.

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No changes to Section K

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RAI Manual, page L-1 and L-2: EDENTULOUS = Having no natural permanent teeth in themouth. Complete tooth loss; lacks all natural teeth or parts of teeth.

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If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgicalwound and not as a pressure ulcer.

Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabeticneuropathic ulcer. The primary etiology should be considered when coding whether aresident with DM has an ulcer that is caused by pressure or other factors.

If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to themetatarsals and the ulcer is present in the 7-day look-back period, code 0 and proceed toM1040 to code the ulcer as a diabetic foot ulcer. It is not likely that pressure is the primarycause of the resident’s ulcer when the ulcer is in this location.

If a resident had a pressure ulcer that healed during the look-back period of the currentassessment, but there was no documented pressure ulcer on the prior assessment, code 0.

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A new “what if” definition to further define “present on admission”

New definitions of tunneling and undermining (RAI Manual, page M-16) , referenced in thedefinition of Stage 3 pressure ulcer on page M-12

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Worsening pressure ulcer is being defined as “increased in numerical stage (RAI Manualpage M-27)

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RAI Manual, page M-36, cancer lesions was changed to e.g. bullous pemphigoid, as anexample

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New items added here.

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N0300: Coding instructions for injections changed to “injections of any type (clarifiers havebeen removed) while a resident of the nursing home. So, intraocular injections can nowbe coded here.

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New field added to N0410

Based on pharmacological classification, as in other categories in N0410

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Resources on page N-8

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TSOAC:Rivaroxaban (Xarelto®) -- Apixaban (Eliquis®) -- Dabigatran (Pradaxa®) --Edoxaban (Lixiana®)

N-10: Herbal and alternative medicine products: These products are not regulated bythe FDA (e.g., they are not reviewed for safety and effectiveness like medications) and theircomposition is not standardized (e.g., the composition varies among manufacturers).Therefore, they should not be counted as medications (e.g., melatonin, chamomile,valerian root).

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RAI Manual, pages N11-N13

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The use of unnecessary medications in long term care settings can have a profound effecton the resident’s quality of life.

Antipsychotic medications are associated with increased risks for adverse outcomes thatcan affect health, safety, and quality of life.

In addition to assuring that antipsychotic medications are being utilized to treat theresident’s condition, it is also important to assess the need to reduce these medicationswhenever possible.

Planning for Care

• Identify residents receiving antipsychotic medications to ensure that each resident isreceiving the lowest possible dose to achieve the desired therapeutic effects.

• Monitor for appropriate clinical indications for continued use.

• Implement a system to ensure gradual dose reductions (GDR) are attempted atrecommended intervals unless clinically contraindicated.

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This decision should be based on the fact that tapering of the medication would notachieve the desired therapeutic effects and the current dose is necessary to maintain orimprove the resident’s function, well-being, safety, and quality of life.

Do not count an antipsychotic medication taper performed for the purpose of switchingthe resident from one antipsychotic medication to another as a GDR in this section.

In cases where a resident is or was receiving multiple antipsychotic medications on aroutine basis, and one medication was reduced or discontinued, record the date of thereduction attempt or discontinuation in N0450C, Date of last attempted GDR.

If multiple dose reductions have been attempted since admission/entry or reentry or theprior OBRA assessment, record the date of the most recent reduction attempt in N0450C,Date of last attempted GDR.

Federal requirements regarding GDRs are found at 42 CFR §483.45(d) Unnecessary drugsand 483.45(e) Psychotropic drugs.

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Updated link to CDC isolation guidelines on page O-5

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The CDC has evaluated inactivated influenza vaccine co-administration with thepneumococcal vaccine systematically among adults. It is safe to give these twovaccinations simultaneously. If the influenza vaccine and pneumococcalVaccine will be given to the resident at the same time, they should be administered atdifferent sites.

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If you leave this item blank, that would be an invalid value and ASAP would reject theassessment. If enter double hyphens, as recommended by CMS, it would be a valid valuebut would count as a zero (0) and would not contribute towards clinically complex RUGscoring. Check your final validation report to confirm it was submitted the way you wantedit to be filled out.

As far as the added guidance/tip regarding qualified dieticians, clinically qualifiedprofessionals, or qualified therapists, there would still need to be a physician’s order inMaine. If you come across specific examples, please let me know and I’m happy to contactthat licensing board for clarification. PT/OT/ST require physician’s order in Maine.

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Are Restraints Prohibited by CMS? (RAI Manual, page P-1) Includes statement by CMSabout the use of restraints and the definition of physical restraints from Appendix PP of theState Operations Manual.

PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material orequipment attached or adjacent to the resident’s body that the individual cannot removeeasily, which restricts freedom of movement or normal access to one’s body (StateOperations Manual, Appendix PP).

CMS is committed to reducing unnecessary physical restraints in nursing homes andensuring that residents are free of physical restraints unless deemed necessary andappropriate as permitted by regulation.

Federal regulations and CMS guidelines do not prohibit use of physical restraints in nursinghomes, except when they are imposed for discipline or convenience and are not requiredto treat the resident’s medical symptoms.

Prior to using any physical restraint, the nursing home must assess the resident to properlyidentify the resident’s needs and the medical symptom(s) that the restraint is beingemployed to address.

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While a restraint-free environment is not a federal requirement, the use of physical restraintsshould be the exception, not the rule.

There are no changes to P0100, Physical Restraints, some of the CFR references have beenupdated if you need to know where to research guidance regarding the use of physicalrestraints.


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RAI Manual, page P-8

While often used as an intervention in a resident’s fall prevention strategy, the efficacy ofalarms to prevent falls has not been proven; therefore, alarm use must not be the primaryor sole intervention in the plan.

The use of an alarm as part of the resident’s plan of care does not eliminate the need foradequate supervision,

There are times when the use of an alarm may meet the definition of a restraint, as thealarm may restrict the resident’s freedom of movement and may not be easily removed bythe resident. (RAI Manual, page P-9)

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RAI Manual, page P-9

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If an alarm meets the criteria as a restraint, code the alarm use in both P0100, PhysicalRestraints, and P0200, Alarms.

Motion sensors and wrist sensors worn by the resident to track the resident’s sleeppatterns should not be coded in this section.

Wandering is random or repetitive locomotion. This movement may be goal-directed (e.g.,the resident appears to be searching for something such as an exit) or may be nongoaldirected or aimless. Non-goal directed wandering requiresA response in a manner that addresses both safety issues and an evaluation to identify rootcauses to the degree possible. (RAI Manual, page P-10)

Alarms do not replace necessary supervision.

Bracelets or devices worn or attached to the resident and/or his or her belongings thatsignal a door to lock when the resident approaches should be coded in P0200F Otheralarm, whether or not the device activates a sound.

Do not code a universal building exit alarm applied to an exit door that is intended to alertstaff when anyone (including visitors or staff members) exits the door.

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Q-1 Intent: Section Q of the MDS uses a person-centered approach to ensure that allindividuals have the opportunity to learn about home and community-based services andto receive long term care in the least restrictive setting possible. This is also a civil right forall residents.

Q0300: examples listed of alternative choices for community living: such as returninghome, or moving to another appropriate community setting such as an assisted livingfacility or an alternative healthcare setting.

This item is individualized and resident-driven rather than what the nursing home staffjudge to be in the best interest of the resident. This item focuses on exploring theresident’s expectations;, not whether or not the staff considers them to be realistic. Codingother than the resident’s stated expectation is a violation of the resident’s civil rights.

Note: Let the resident know that they can change their mind about requesting informationregarding possible return to the community at any time and should be referred to the LCA ifthey voice this request, regardless of schedule of MDSassessment(s).

Local contact agencies (LCAs) are experts in available home and community-based service

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(HCBS) and can provide both the resident and the facility with valuable information.


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Section S Manual, page 3: The PASRR Level I screen is the preliminary screen conducted onall persons seeking admission to a Medicaid certified nursing facility (NF) or skilled nursingfacility (SNF), to identify individuals with major mental illness, intellectual disability, orother related conditions. Maine requires the completion of a Level I Screen on all peoplebeing admitted to an NF, even if the expected length of stay is 30 calendar days or less, as away of following these individuals in case they remain at the facility for permanentplacement, at which time a Level II Assessment may be required.

When you complete your annual or significant change in status assessment and youdetermine that there has been new, sudden or exacerbated emotional, behavioral, mentalhealth problems and/or new medications or diagnosis RELATED to mental health ordevelopmental disabilities that was not known at the time of your last pre-admissionscreening you will need to complete a pre-screening and refer for Level II review. You willanswer yes to MDS 3.0 Item S0510 and record the date of your Level I Screening in MDS 3.0Item S0511


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The Level I screening process makes only two determinations:

• There is no known or suspected mental illness, intellectual disability or other relatedcondition, or

• There is a known or suspected mental illness, intellectual disability or other relatedcondition.

• If the outcome indicates there is a known or suspected mental illness, intellectualdisability or other related condition, the outcome is forwarded to the State’s PASRRCoordinator.


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No changes to Chapter 5: SUBMISSION AND CORRECTION OF THE MDS ASSESSMENTS

And last but not least….

One minor change to Chapter 6-56: change of reference to definition of LOA, now Chapter2, section 2.5 rather than 2.4

And a few regulatory changes that will have impact on the MDS>>>

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This means that if a resident has a hospitalization or otherwise qualifies for a significantchange in a mental or physical condition, a referral must be made for a PASRR level I andthan a subsequent Level II screen, as indicated. A new PASRR Level I will be captured inSection S. An updated Level II screen will be captured in Section A.


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Any topics you would like to have covered as part of the forum call in November?

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November in Portland, potential plan for another 2-day training. Please email if there isinterest so that we can accurately assess the need, interest, and locations.

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10/11/2017

We are very excited to be welcoming a new nurse this month

MDS 3.0 Changes Effective 10/1/17

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10/11/2017

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