Reducing errors

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Staff at The Terraces at San Joaquin Gardens in Fresno, CA, focus on a team approach to promote MDS accuracy.
Staff at The Terraces at San Joaquin Gardens in Fresno, CA, focus on a team approach to promote MDS accuracy.

Any process that starts with a manual more than 600 pages long will be ripe for misinterpretation.

Factor in overloaded coordinators, hectic work conditions, complicated schedules and medical terms that don't match regulatory speak, and MDS 3.0 mistakes are almost unavoidable.

But the complex evaluation tool that guides care and ultimately determines facilities' pay rates is under increased scrutiny, and that means even unintentional errors could become more costly.

“It's all very tight and coordinated,” says Leah Klusch, RN, BSN, and executive director of The Alliance Training Center. “When things change or if facilities have not created good data, it can create a lot of negative outcomes for the whole operation.”

Patient care plans might be lacking, reimbursements might be lower than deserved and litigation can lead to repayment. Error-riddled data also can undermine confidence in an institution if it lowers Five-Star quality ratings that feed the Nursing Home Compare website.

A 2013 OIG report that found that nearly 40% of skilled nursing providers failed to care for residents as planned. Another OIG report found almost half of the skilled nursing facilities reviewed had inaccurately coded the MDS relative to the medical record.

In a webinar this spring, PointClickCare's Jayne Warwick, RN, reported that the 2014 pilot for Focused Surveys found deficiencies at 24 of 25 sites. The wider round of 2015 Focused Surveys was scheduled to wrap by the end of September.

But auditors will almost certainly be looking for similar information in the future, especially with a shift to pay-for-performance and outcomes-based care.

“You have a right to get paid for the care you provide,” says Judi Kulus, NHA, RN, vice president of curriculum development for the American Association of Nurse Assessment Coordination. “But when you make mistakes, you don't get paid or you get a low payment. That piece creates immediate pain.”

Making mistakes also undermines the potential gold mine of information compiled during the MDS process.

Klusch has seen physical therapists use information to judge the effectiveness of a fall prevention program and pharmaceutical consultants review it for antipsychotic use. It also can indicate staffing needs.

McKnight's Long-Term Care News asked consultants and vendors who provide MDS training and software about mistakes most commonly made by skilled nursing providers, and how to improve efficiency and accuracy. [When asked to detail common mistakes its auditors see, CMS only provided an old memo outlining errors found in the 2014 pilot.] 

Most common mistakes

1. Non-matching clinical documentation

MDS and special assessments ought to be byproducts of good daily documentation, says John Ederer, NHA, president of American Data.

“As a bonus to daily patient-centered assessing, the bottom line is improved by taking daily credit for all the work that is being done by the hands-on caregivers,” he says.

But in 25 site visits during 2014's focused pilot, surveyors found disagreement about the presence of pressure ulcers in 55% of cases in Minnesota.

Often, such problems are created because nurses charged with resident care have a different vernacular than what's required by the RAI.

“The MDS nurses commonly found in skilled nursing facilities are clinicians first and financial representatives second, if at all,” says Maria Moen, vice president of care innovation at VorroHealth. “They are oftentimes ill-prepared for the complexities of MDS completion and submission.”

The challenge of correctly referencing conditions and treatments will likely grow worse this fall, says Linda Spurrell, LPN, project manager for clinical applications at NTT Data. The latest changes to the  MDS will include a conversion Oct. 1 to ICD-10 classifications, which Spurrell says aren't “remotely the same” as ICD-9.

Nurses and MDS coordinators who aren't trained on the changes — or don't have the latest manual updates in their facilities — will spend more time trying to convert information from charts or submit it wrong, perhaps unwittingly.

Kulus says administrators need to give MDS coordinators time to do their job and check that resident observations, medical records (possibly including therapy logs) and the MDS align. 

2. Missing key dates

Coordinators should have a calendar for each resident to ensure timely completion, avoid errors and capture the optimal RUG rate, says Kitty Williams, RN, research and development director for The Compliance Store.

In facilities that juggle Medicare residents and the insured, different standards apply. Knowing whether a resident needs an OBRA assessment or a PPS assessment, and when, can mean the difference between getting paid for services delivered, getting a lower payment for late submission or getting no payment at all.

“When you're dealing with hundreds of patients, or if you don't have software or a spreadsheet, it's easy to miss one,” says Rob Moore, RN, clinical quality assurance specialist for AOD Software. He says date-related mistakes are most likely to happen in facilities with high Medicare rolls and overloaded employees.

Programs like AOD's Answers are built to track upcoming timeline requirements for each patient, its makers point out. Software can help managers anticipate if a target date falls on a Sunday or during a planned vacation.

Software also can determine if it's OK to combine certain assessments, says Spurrell. If that's done inappropriately, a facility needs to inactivate, correct and resubmit. Failing to do so can skew quality measures and Five-Star scores when non-Medicare residents end up included.

Printing out impending deadlines for morning stand-up is one way to stay on task, Moore says. 

3. Failure to optimize

Although strict, the MDS process allows some breathing room. Too many fail to use the best assessment reference date, depriving themselves of payment.

While this isn't a finable offense, it can impact the bottom line. An initial ARD, for instance, that falls closer than strictly necessary to admittance might not account for the lag time between facility entry, clinical exams and start of high-volume services.

Moore says facilities using paper records are at a marked disadvantage: It can take hours to calculate options and determine the best ARD. Algorithms quickly pick a preferred date range based on both manual specifications and data or prospective therapy minutes that have been entered.

Software can determine whether a facility has committed more services via nursing or therapy during a given period.

Consultants often are hired to ferret out a strategy that frees coordinators from blanket date-selection policies. After all, the difference between a single rehab medium day and an Ultra-High day could be $142, experts say.

Though Ultra-High designations tend to draw the attention of auditors, Moore says facilities whose residents' conditions and therapy logs support their MDS coding have nothing to fear.

4. Underreporting ADL help

In Illinois last year, focused surveys found a 24% disagreement between MDS submittals and medical records for assistance with activities of daily living.

Lori Elrod, marketing manager at PointClickCare and a former admissions director for a 190-bed skilled nursing facility, says assistance is often estimated rather than recorded when provided.

“Imagine a CNA is caring for eight to ten patients,” she says. “It's so hard to remember after an eight-hour shift all the times you needed help to move Mrs. Jones.”

Patient conditions change from morning to night, day to day. A shift toward greater dependence may bring higher reimbursement but it can also indicate a change in the patient's condition, says Elrod.

Point-of-care charting via electronic health records can help, as can programs that automatically know how to code for quirks such as the Rule of 3.

There also are struggles with tracking incontinence. Site visits and interviews can reveal gaps.

5. Warnings ignored

Facilities that don't give MDS coordinators a quiet workspace can end up with incorrectly keyed information, says Klusch.

Data platforms are created to catch mistakes, but experts say they are often overlooked or misunderstood.

“Warning signs are there to assist you to not make an error,” says Williams, whose company's online library includes the up-to-date Casper user's guide and a provider's guide.

Kulus suggests using, a website for the QIES technical support office, to troubleshoot error messages.

In a facility where Carol Maher, RN-BC, once worked, the fiscal intermediary denied four claims because the MDS was not in the federal database. The submittals contained errors in the resident identifying information, including Medicare numbers, an incorrect spelling and incorrect birth date.  

Maher, now director of education for compliance auditor Hansen Hunter & Co., says the system sometimes gives only one opportunity to catch such mistakes.

“If the MDS coordinator is not reviewing ALL of the final validation reports, he or she may miss the error messages regarding new data,” she says. “This also should have been caught during a triple-check.”