EDITOR’S NOTE: Respected long-term care payment and assessment expert Leah Klusch is sharing with mcknights.com readers her observations from the front line of the sold-out 2012 MDS 3.0 National Conference taking place this week in St. Louis.

It was a long first day, but there was tremendous value and everyone who is here has learned what the Centers for Medicare & Medicaid Services’ positions are with the April updates and some of the policy changes they’re talking about. The changes are thought provoking and some are what I would consider on the edge of being a little controversial.

We have a lot of details that are going to change our fundamental practices on how we set assessment reference dates, how we use observation periods and change of therapy assessments, and how we deal with discharges under the new definitions of planned and unplanned.

It was a good first step, but we’re not quite there yet. I’m sure we’ll get more communication before April 1 — when many changes take effect.

Tuesday’s packed agenda started at 8 a.m. and ending with probably more than an hour of Q&A at 5:30 p.m. There was also Q&A in the morning. 

The audience was very experienced, I think about 700 people. A lot of administrators, MDS nurses, corporate MDS consultants and industry consultants. There were a lot of “big players” who have been a part of this for years and they came well-prepared with questions.

Discharge dissension

In the morning, we started reviewing changes to the MDS 3.0 document that will be implemented April 1. There are a lot of issues and terminology that are changing with the manual and the actual form itself. That held very few surprises, except for the area dealing with planned and unplanned discharges. They’ll continue to be discussed because the difference between the two has not been clearly defined. There are a lot of unique circumstances about discharges.

For example, if someone is supposed to go home on Thursday, and Tuesday morning the resident says, “I’ve decided to go home today.” That’s two days early. When you do a discharge assessment, is it “planned” or “unplanned”? Technically, this could go under both.

That generated a lot of discussion. I don’t think the people at CMS understood how fluid the discharge system can be sometimes. 

In April, if you have an unplanned discharge assessment, you don’t have to do the interview on it. If it’s planned, you have to do the interviews. There’s a big change. It makes a big difference in the workload. The fact they took the interview out of the unplanned discharge is VERY positive. Yet, how they define that group is yet to be decided.

There was a lot of controversial discussion about the correction of MDSes and inactivations, along with the active discussion about planned and unplanned discharges.

There was also a lot of discussion about the manual coming out and CMS issuing a correction document last week, which they ended up retracting because it was wrong. Attendees actively requested that before regulators put out any more of these corrections, they make sure the documents are reviewed. 

The CMS people were congenial and understood the delay is disruptive during a time when we’re trying to train people to do something different.

Talk about combos

We also had an interesting discussion about MDS 3.0 and RUGs-IV. CMS officials presented statistics about the differences in the various categories and some therapy categories between 2011 and the beginning of 2012. They didn’t show a lot of difference between the two years.

Another good part was the discussion about combining assessments and when you can and can’t do it. There are some enhanced directions on that that go into place April 1. Again, I don’t think CMS was ready for some of the specific questions from the audience about special circumstances.

But the people from CMS were very welcoming and wanted examples written down so they could take them back and consider them.

They also presented new material on the implications for combining assessments, setting ARD dates and inactivation of assessments where there are mistakes. It was thought provoking at the least, and somewhat problematic for providers because some of the rules they’ve set for these assessments could have a significant impact for operators who are not really on top of their assessment process. 

If their people haven’t been trained, done have up-to-date manuals with all the directions in them, or if the corporations have policies about handling these circumstances and now there are new rules, the policies have to be changed rather quickly. That’s somewhat problematic.

I think Wednesday there will be some more discussion carried over from today because at the end of [Tuesday], there really wasn’t a resolution for these new definitions. The players from CMS were open, but I don’t think they were ready to change policy. 

One major suggestion from the audience was to put things like the unscheduled assessments and inactivation of assessments out to the industry first when there are big changes and refinements like this. CMS originally threw this out there without putting it to the industry first.

My personal impression is they’re going to take a hard look at this. The industry may have an opportunity to respond at some point.


Tool to analyze workflow

Another thing that happened that was very, very positive is officials went over the reports and the error messages relating to validation. They now have some statistics as to why MDSes don’t validate. 

One of the things that was very surprising is the fact one major area of errors was duplicate records. Sometimes it’s just a double-click on a computer. Other times, it’s a systems issue. That surprised me a bit. Duplicate assessments, missing items, inconsistent dates, and sequencing were top mistake areas.

One of the things operationally we’re trying to do in the industry is identify workflow and productivity and assessment activity in a given building, which is something that has not been isolated in most LTC facilities.

If I ask an administrator how many MDSes they do in his building in a week, very few would know. Now, government CASPER reports are helping keep track of MDS activity, and what types errors are made. They can see on a weekly or monthly basis what a provider’s productivity is. Everybody had an opportunity to think about this new analytic and see how the MDS activity report might be used to determine the workload in the building.

Quality Measures in play

This discussion was very, very specific. It was connecting the QMs to the traditional survey process. We learned how the state surveyors are going to use the Quality Measures. A new report won’t be an April 1 release but sometime later.

State surveyors are going to use fewer quality measures than the total Quality Measure program collects data for. Everything is not finalized yet, but at least we had the opportunity to see the preliminary reports the surveyors may use.

One thing they’re not going to do is use any of the QMs involving immunization. Another thing they WILL be using is the weight-loss and weight-gain statistics, which are new in Section K. Another one that I think is really important is they’re going to be looking at residents in hospice and dialysis. They’re also going to look at any resident receiving specialized rehab services as a total group.

It isn’t finalized, but it was very well accepted. The group in general was extremely positive about the fact that they’re getting to look at it.



People need to go to the CMS MDS 3.0 website and make sure they have the information about the new form.

One key thing is you have to get an updated MDS manual for April 1’s changes. My recommendation is not to try to duplicate your old manuals. Buy new. There are so many updates, it’s too much work to go through the building and update every manual. Then, you need to get your team together and explain the changes.
I’m looking forward to Wednesday’s sessions. We’re going to spend the entire morning talking about discharge planning and Section Q, which has changed more than any other on the form.

Then we’re going to care planning issues and talk about care area assessments. The April manual has a lot of refined directions on how to do care planning.


Hop aboard … or else

Providers are going to have to take a hard look at how they schedule and complete assessments. And because we’re moving into change, we have to retrain people.

All providers need to get themselves invigorated about this, no matter how they do it. There will be plenty of negative financial implications if they don’t.

Leah Klusch, is the executive director of The Alliance Training Center. A 45-year veteran of working with provider assessment and payment issues, she is also a McKnight’s Online Expo keynote speaker (“Making the most of the newest MDS 3.0”) at 9 a.m. on March 21. Registration and the accompanying continuing education credit for her session are both free.