MDS 3.0: Worst over?

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MDS 3.0: Worst over?
MDS 3.0: Worst over?
Months have passed since MDS 3.0 took effect, and in many cases, time has helped long-term care operators — and even software vendors — eliminate some of their most troubling transition woes.

The bridge period began as a logistical and implementation nightmare in October, thanks to software glitches stemming from last-minute regulation changes and weeks-long computer coding errors at the Centers for Medicare & Medicaid Services. But now things have seemingly settled down for many providers.

“The transition period was difficult because of software and CMS problems, and just trying to get to know the process, but it has definitely gotten easier. I would say we are doing very well,” says Flora Macatangay, RN, BSN, director of clinical assessments, standards and practice, Trinity Senior Living Communities, Livonia, MI.

Others echo that sentiment. One software executive, for example, noted that the implementation of MDS was essentially a “non-event” for the company's customers, thanks to targeted education, advance preparation and prompt software enhancements.

“They did not miss a beat in providing high-quality care while ensuring that the new assessments were completed accurately and on time,” says Steve Pacicco, CEO of New York-based SigmaCare/eHealth Solutions Inc.

Of course, getting to that point hasn't been easy. And it's possible that problems are still percolating beneath the surface, unbeknownst to some providers, explains one seniors housing consultant.

“I think, in some cases, the noise has died down because people aren't really aware of the problems that still exist,” says McKnight's “Ask the Payment Expert” columnist Patricia Boyer, MSM, RN, NHA, who is president of Boyer & Associates, Brookfield, WI.

Issues still surfacing
One MDS 3.0 “fix” that could come back and bite some providers and software companies relates to software patches that, in some cases, served as a Band-aid, as opposed to a full-scale remedy. As Boyer explains, some software vendors put patches on their systems that were effective only from the date those patches were implemented. Some facilities are discovering they now need to go back and make adjustments for data entered prior to the patch's implementation.

“If a patch was put in place in November, for example, facilities may need to go back and look at the entire month of October and make manual adjustments,” she says. “If the software was coded incorrectly, that means facilities are being paid incorrectly. I'm not sure facilities are monitoring this very closely.”

In some cases, critical rate categories may even be missing from vendor software. Boyer says she ran a report in one Wisconsin facility and discovered that the software vendor hadn't included the RUG-IV 48 grouper fee-for-service rates in its program, even though Wisconsin is a Medicaid case-mix state and requires resident assessments that are classified under the 48 grouper.

Another unforeseen issue that could hit reimbursement rates hard pertains to CMS' new sum score for the RUG system, which Boyer says is causing some facilities to have lower Activities of Daily Living scores.

“I'm seeing a lot more A's than B's and C's on RUG levels, and more A's means lower payment,” she says. “The way the new summation is done now, you could actually have a person with one or two areas of extensive assistance, but just because only one person was involved in physical assisting, it's being coded an A.”

That lower ADL score could potentially spell even bigger trouble in the event of a medical review, whereby the reviewer could refer to those scores to question whether a resident really requires the level of therapy being provided, for example.

“It is so important that we train our staff — especially our CNAs — how to accurately code ADLs. That's always been an ongoing issue, but it's more important now than ever,” Boyer reasons.

Accurate reimbursement also hinges on a strong partnership between the MDS coordinator and rehabilitation or unit manager, adds Aysha Kuhlor, RN, BA, CNONA, director of clinical services for St. Mary Home, West Hartford, CT. She advocates scheduled, ongoing meetings between the two disciplines.

“Coordinating the RUG distribution process will increase revenue and decrease potential oversights,” she says.

Don't rush the process
Not surprisingly, MDS 3.0's resident interview component continues to be providers' biggest challenge. While sources agree that the process has its merits — particularly in its ability to improve communication with residents and create a more holistic approach to care — it's the time commitment that's left many staff members flustered.

“The job of our social worker has increased twofold because of the assessments, and it's extra work for our nurses, too,” says Bunny Schoeneck, care coordinator for Spring House Estates, an ACTS Retirement Life community in Lower Gwynedd, PA. In January, the facility conducted 43 unexpected assessments — in addition to the normal expected number.

The Personal Health Questionnaire Depression Scale (PHQ-9), in particular, is proving a challenge for some providers. “We've found that questions relating to suicide can be especially difficult for some residents and their families,” says Schoeneck. “These are very important questions, though, because many [residents] may show signs of depression. We have to do what we can to make people more comfortable about answering them honestly.”

Carving out adequate time for the interview is essential, as is securing a quiet location to dodge distractions.
“If you just go in, tell the resident you have a few questions and then run through it quickly, that's going to give you a very different set of answers than if you're really setting the stage, taking the resident to a quiet area, and explaining the process so they feel comfortable to tell how they're really feeling,” explains Boyer.

Hasty questioning also can lead to lower reimbursement, she warns, because a resident may respond that he or she is feeling fine, even if that person has clear depression indicators. Taking an extra moment to refresh a resident's memory is also helpful. This is particularly true when interviewing those with memory deficit because it can help elicit a more accurate response.

If a resident experienced crying episodes, or had been more withdrawn the week prior, for example, Boyer says it may be helpful to refer to that incident and then explain that questions will be asked to help determine how he or she is feeling now.

To make the most of each resident interview and promote privacy, the social worker at Spring House Estates posts a sign on the door indicating that a conference is in session.

“She needs peace and quiet, and so do the residents because they can become easily distracted,” says Schoeneck. “You don't want nurses coming in to pass meds, for example, when you're trying to conduct an interview.”

Some other small adjustments can help make the most of available time, and even reduce supply costs, which some facilities have seen skyrocket since they began printing the more detailed and lengthy assessments. Boyer now encourages facilities to print just the Section Z and V signature and CAA(s) sheets, which is the minimal CMS requirement.

“These MDSs are so big and cumbersome and people can't fit them in their charts,” she notes. She also suggests placing Section Z in the chart so  that those who are completing the interview can sign off immediately.
“This is a small change that can make a big difference because it eliminates the need to spend time getting signatures after the fact,” she explains.

Take a team approach
Facilities committed to a collaborative approach are finding it easier to navigate the challenges of MDS 3.0. And sources agreed that's especially the case where resident interviews are concerned.

“Putting all your eggs in the MDS coordinator's basket is a mistake,” says Norme Torres, executive director of Mather Pavilion, Evanston, IL. He adds that all staff members at the community are trained to conduct interviews.

“It's important to make residents comfortable, and it's great to be able to have the person who has the best relationship with a resident be able to step in,” Torres says, adding that he, too, has taken on the interviewer role, as needed.

The team approach also can prove invaluable for helping staff circumvent obstacles that could impede an effective interview.

“When you have everyone working together, you get more valuable feedback about residents that will help you determine the best time to do the interview. One employee may know that Mrs. Jones down the hall doesn't like to be disturbed before 9 a.m., for example, and a therapist can share if a resident was exhausted from a session and probably shouldn't be bothered until after they've had enough time to rest,” explains Torres. “[MDS 3.0] is much easier to manage when you're working as a team and bringing all these important pieces together.”