One section at a time
Experts advise that both nursing and therapy staff members should know how to code Section GG, which goes into effect Oct 1. Facilities also should determine which staff can handle the assessment docu
When it comes to the Minimum Data Set, accuracy can be the defining factor in whether a facility keeps its doors open, thrives or ends up facing federal indictment.
Whether providers are looking to ensure they can afford to provide the proper care their residents need or to maintain a five-star quality rating, the information listed in the assessment form has lasting effects on all involved.
Experts note that some sections are harder to complete correctly than others. Specific strategies can make a big difference.
Time to talk
The interview sections of the form are where experts say they have seen a substantial number of mistakes. Sections C, D, F and J all require direct input and personal responses from the residents themselves.
Problems with these interview sections often occur when providers struggle to gather the needed information by the form's deadline. Proper time management, keeping track of which interviews have been completed, and compiling responses all need to be conducted in a timely manner to achieve success.
With an abundance of information moving through these sections, technology can ease the process, says Ray Alameda, a business analyst for MatrixCare.
“The data on the MDS must be accurate. This can be simplified by having software capable of capturing observations as they occur,” he says. “Whether recording ADL information or therapy minutes or completing an assessment, using software helps to build the supportive documentation.”
Providers should work with residents to streamline the process, recommends Judi Kulus, vice president of curriculum development for the American Association of Nurse Assessment Coordinators. She advises arranging a time to conduct the interviews with residents in advance. That allows for an ideal setting for accurate information to be gathered.
“I joke about it, but sometimes the nurse will say, ‘I want to go on my smoke break in five minutes. I'll run by and see if [the resident] is available.' You go to the room and they are in the middle of watching their favorite show, ‘Wheel of Fortune' or whatever it is,” Kulus says. “They aren't wanting to talk to you at that point and even though it may be convenient for you, it may not be convenient for the resident.”
She adds that showing genuine concern for what residents have to say during the interviews is not only respectful, but it also produces more accurate results.
Troubles with the MDS are not limited to communication. Many providers have reported issues with correctly coding medical conditions such as pressure ulcers and infections. Properly coding oral and dental problems also is an area of concern.
Under Section M, nurses are required to document appearance, size and several other factors of any pressure ulcers. Similar steps are needed to complete Section I, which focuses on the presence of healthcare-associated infections, and Section L, which looks at a resident's oral conditions. If documentation from these sections is inaccurate, providers will be penalized and residents' treatments may be altered.
The first step to filling out these sections correctly is to ensure that staff members are properly educated on how to identify and define conditions, says Leah Klusch, RN, BSN, FACHCA and executive director of The Alliance Training Center.
“The MDS terminology is specialized and the average nurse, dietitian or social worker may not know exactly how to define something on the form,” Klusch says. “The biggest example we see today in that area is with urinary tract infections.
“The MDS process has a very specific definition of when you code a urinary tract infection, and a lot of times the nurses don't understand that and will just write it in the records. Then, an MDS nurse that hasn't had training will pick that up, put it on the MDS and it doesn't qualify under the proper definition.”
She adds that improperly coding these medical conditions also can result in a facility's five-star rating dropping significantly.
Section L is overlooked so frequently as a result of a lack of education, it has become a target of external audits, notes Gloria Brent, CEO and president of MDS Consultants LLC.
“Nurses often skip over Section L and don't know how to read the dental documentation because it is a little tricky to learn,” Brent says. “It is the highest section I have encountered that receives a state health deficiency. “
Addressing these discrepancies lies in continually educating staff members and consulting the Resident Assessment Instrument Manual. Experts note that the manual includes step-by-step instructions on how to document, define and code all the conditions listed under the three sections.
Klusch and other experts call the manual the ultimate resource for those struggling to accurately complete MDS sections.
“It is important that all instructions related to a particular section are read, including the steps for the assessment, coding instructions, coding tips and definitions,” says Ronald Orth, senior analyst for specialized nursing facility regulations and clinical reimbursement at Relias Learning. “More often than not, the questions I receive are easily answered by referring to the RAI manual.”
Coding errors also are said to regularly occur in Section G, which assesses activities of daily living.
The requirement to monitor patients 24 hours a day for seven days, while also incorporating the rule of three, arguably makes Section G the most tedious. Many providers look to software solutions to record the resident's every move during this observation period.
“CNA staff are busy and need systems to enhance their ability to document appropriately,” says Joel VanEaton, director of clinical reimbursement at Care Centers Management Consulting. “The use of quality, intuitive electronic ADL capture software is a must.”
He adds that a number of the errors in this section are a result of nurses misunderstanding the guidelines. Consistent re-education and follow-ups also are needed in this section to achieve accurate coding.
Applications that help calculate ADL scores are used by a large number of providers to help ensure nurses' observations are properly evaluated. These programs not only provide a step-by-step guide to documentation but also serve as an educational tool.
While providers are dealing with complications in these sections and several others, their attention also should be quickly shifting to the changes to the MDS coming Oct. 1. Above all, providers are stressed over the addition of Section GG.
Departing from the standard form of data collection used throughout the MDS, this new section will be based on evaluations from the resident's start and end dates. With 16 new areas to monitor in the mix, providers have been working frantically to prepare for the new section.
MDS consultants have placed an emphasis on downloading the new data sets and the draft RAI manual to help operators prepare for the implementation. They also say facilities need to create new procedures to address the added evaluation requirements.
Brent notes that residents often achieve better results in these type of evaluations when they are observed during therapy, versus relaxing in their rooms. She also says determining who will handle the documentation is essential.
“Both nursing and therapy need to know how to code Section GG,” Brent says. “It would be a good idea to determine if nursing would be best to do [the assessment] upon admission and if therapy would be best to handle the documentation during discharge.”
Despite the uncertainty surrounding the new section, Kulus says it can be a tool to improve care, if viewed in the right light.
“If we look at it as a positive improvement on resident care — setting aside the quality measurement, setting aside the payment impact — and put a system in place in facilities that fosters resident voice and good quality care, that's going to be fantastic,” Kulus says.
From software solutions to establishing better communication, there is a wide variety of options to help providers navigate through MDS trouble areas. With resident care and a healthy bottom line at stake, completing all sections accurately is a must. But it will take more than simply writing down the correct information.
“Executing high-quality MDS work requires a thorough understanding of the RAI Manual, exceptional organizational skills, attention to detail, staying up to date with the changes, finding joy in being a detective and, above all,” VanEaton says, “a love for nursing home residents.”