Providers are simultaneously coping with significant changes to survey guidelines and increased oversight, making it more important than ever to develop a responsive and well-informed staff, a compliance expert said in a McKnight’s Super Tuesday webcast.
“The continuum of regulatory oversight and the development of the database that the facility is sending in are coinciding now, so the regulators have a lot more specifics when they come in, which many times does take the provider by surprise,” said Alliance Training Center Executive Director Leah Klusch, RN, BSN, FAHCA.
In particular, surveyors are focused more than ever before on the accuracy of assessments, Klusch noted. Documentation must be accurate from a clinical perspective, and reflect the resident’s wishes, she stressed.
Major updates to the RAI manual in April 2012 and May 2013 are among the changes that are challenging operators. Klusch focused on a number of areas, including pressure ulcer documentation and incontinence assessment and care.
Section M, dealing with pressure ulcers, was the most thoroughly revised part of the manual in the May 2013 update. Klusch advised copying the entire section to make sure all clinical leaders and facility decision makers understand the new definitions and other changes, including an expanded definition of moisture related skin damage. Minimum Data Set coordinators should exercise extreme care in coding for pressure ulcers, and should confer with wound care nurses as necessary, Klusch urged. Surveyors are using this data “significantly” to “evaluate care practices and outcomes.”
Too many residents are being inaccurately coded as totally continent, Klusch said, adding that surveyors are likely to be “very aggressive” if they discover this as being miscoded. She outlined a number of steps providers should take to maintain compliance with the enhanced Section H coding around toileting, including thoroughly documenting the first three days of a stay, ensuring coordination between therapy and nursing, and speaking candidly with all residents about the issue.
Klusch also spoke in detail about admission documentation, weight stability and falls. She advised providers to plan for another update in September, which will include new standards for coding therapy.
The full webcast is available for viewing in archive at mcknights.com/expo2013