South Carolina:
Tags: No MDS Policy, Multiple coding issues identified: UTI coded without criteria, antipsychotics coded incorrectly and no documentation to support GDR, Wounds in Section M do not match wound documentation (MDSC says they never have the wound report timely), surveyors watched 6 wound care, 3 cath care, and 1 pericare.
Florida: No deficiencies
Saturday, September 5, 2015
Reminder for North Carolina LPNs: You are Not Allowed to complete CAAs by NC Board of Nursing Scope of Practice
North Carolina Only:
From Mary Maas, NC RAI Manager on the NC MDS email list-serve:
From Mary Maas, NC RAI Manager on the NC MDS email list-serve:
Below you will see the BON’s position statement issued following an exchange of emails between Cindy DePorter and Carol Walker from the NC Board of Nursing published August 2010.
Mary Maas
LPN Participation in MDS 3.0 Portion of CMS RAI
The laws and rules governing nursing practice in North Carolina require that an RN is responsible for the nursing assessment of clients. Nursing law and rules give the RN comprehensive assessment responsibility for the determination of nursing care needs based on the collection of data, interpretation of all data (whether collected by the RN personally or by another competent individual), and formulation of a nursing diagnosis. The RN also is responsible for developing and modifying the nursing plan of care and for evaluating the extent to which desired outcomes of nursing care are met.
In contrast, nursing law and rules allow an LPN to “participate in” the nursing assessment of clients. The rules define this participation as the collection of client data using written, structured guidelines, policies or forms. This is sometimes identified as a “focused assessment.” The documented focused assessment completed by an LPN is then used by an RN in the completion of the comprehensive nursing assessment of a client. The rules further specify that data interpretation by the LPN is limited.
It is essential to note that the nursing assessment of a client is required on admission and on an ongoing basis independent of, but in collaboration with, the initial and ongoing RAI process. The nursing assessment and nursing plan of care will incorporate data collected on the MDS and throughout the RAI process but will require additional data and guide interventions based on the RNs ongoing independent assessment and evaluation of client condition and nursing care needs. As CMS notes, “the process of completing the MDS and related portions of the RAI does not constitute the entire assessment that may be needed to address issues and manage the care of individual residents” (CMS’s RAI Version 3.0 Manual, June 2010, Pages 4-7&8).
The Practice staff of the Board has reviewed CMS’s MDS 3.0 form, the CMS guidelines and intent statements, and consulted with several resources. As a result, we understand that the RAI, including all three components of MDS, Care Area Assessments (CAAs), and Individualized Care Plan, meets CMS’s requirement for a documented comprehensive assessment of the client. The MDS is the starting point for this comprehensive assessment and when it is completed, provides a foundation for a more thorough assessment and the development of an individualized care plan.
The Board’s determination is that the MDS 3.0 is a structured assessment form used for the purpose of data collection and, as such, falls within the scope of practice of the LPN in North Carolina. The LPN is responsible to sign the certification statement for those portions of the MDS for which they collect and document data. We understand that the RN Assessment Coordinator’s signature indicates that all portions of the MDS have been completed by those appropriate to do so, and does not indicate validation or accuracy of any portion. However, interpreting and addressing the identified CAAs or care areas and developing/coordinating the individualized care plan are beyond the scope of practice of the LPN. This level of assessment, interpretation, and planning is within RN scope of practice. The RN collaborates with the attending physician and other health professional members of the interdisciplinary team as indicated by client condition and care needs.
Wednesday, September 2, 2015
Fourth MDS Focused Survey in Virginia
One F278 MDS accuracy citation, 4 of 10 charts. Richmond area.
Here's the summary:
Here's the summary:
They entered Tuesday after lunch and exited Weds. On entry, they asked for the regular survey stuff: floor plan, key personnel, contacts, 672. They asked for list of Admissions/ Discharges for past 90 days including details of where admitted from/discharged to.
They asked for policies and procedures on Pressure Ulcers, Catheters, Restraints, UTIs, Falls, and Anti-psychotics. They did not immediately ask for P & P on Staffing/Scheduling or Resident Assessment Instrument but were given these later.
They gave us copy of Worksheet 1 (previously distributed). They did not appear to pay any attention to the column on Extensive Assist of 2. From this, they selected a sample of 10 residents for review.
Surveyors immediately verified that staffing was posted as required. Surveyors also requested 18 months of staffing sheets.
They looked at most recent MDS completed for the 10 residents in sample, regardless of whether it was OBRA or PPS assessment. They did not look at any MDSs in progress. In this facility, during MDSC vacancy, another IDT member was assigned to complete interviews. Not all interviews were completed during this time and we were cited for missed interviews on 3 of 10 residents reviewed. One pt reviewed had order for “Seroquel for anxiety.” In Section N, the MDSC coded this as Antianxiety med. This is incorrect per RAI Guidelines. Medications are to be coded on the MDS based on the drug classification, not its use. This was included in citation for inaccurate resident assessments.
Surveyors observed wound care on 2 patients but gave no citations for quality of care.
Note from Judy:
Never give a surveyor an MDS "in progress." If it's not attested to, it's not an MDS yet.
One more to go and Virginia will have it's five. They are supposed to be done by the end of September. If you are a Virginia provider and have had the 5th MDS focused survey, please let me know the results. Thanks!
Monday, August 31, 2015
Two MDS/Staffing Focused Surveys in Virginia, THIS MAKE 3. WE ARE LOOKING FOR TWO MORE.
First Virginia MDS Survey:
2 deficiencies –
1 tag ---unnecessary med (resident sent out to hospital x 2 days and when he returned we failed to reactivate behavior monitoring on the MARs for his Seroquel,
another tag ADM – incomplete, inaccurate medical record tag on same resident for having the seroquel listed as PO on MARs when it was given via PEG
Second Virginia MDS Survey:
Three citations:
F278 MDS Accuracy:
Missed coding a UTI on a quarterly. The surveyor correctly identified the four criteria for coding UTI and they were all in the chart. It was just missed by the MDSC.
Coded an indwelling catheter when it was discontinued prior to the lookback
Incorrectly coded a pressure ulcer as unstageable when it was Stage IV. It had been unstageable prior to lookback but was stage 4 in lookback.
F329 unnecessary drugs
failed to monitor for effectiveness, side effects, interventions and behaviors for Seroquel on two residents. Seroquel with inadequate reason for one resident.
F356: Didn't post staffing per requirements
Judy's opinion on this one: These MDS citations suggest to me that they may have been copying and pasting previous MDSs without verifying accuracy for lookback
THIS IS THREE VIRGINIA SURVEYS NOW. WE ARE LOOKING FOR TWO MORE THEN WE ARE DONE FOR THIS FY. IF ANYONE KNOWS OF THE OTHER TWO, PLEASE LET ME KNOW.
2 deficiencies –
1 tag ---unnecessary med (resident sent out to hospital x 2 days and when he returned we failed to reactivate behavior monitoring on the MARs for his Seroquel,
another tag ADM – incomplete, inaccurate medical record tag on same resident for having the seroquel listed as PO on MARs when it was given via PEG
Second Virginia MDS Survey:
Three citations:
F278 MDS Accuracy:
Missed coding a UTI on a quarterly. The surveyor correctly identified the four criteria for coding UTI and they were all in the chart. It was just missed by the MDSC.
Coded an indwelling catheter when it was discontinued prior to the lookback
Incorrectly coded a pressure ulcer as unstageable when it was Stage IV. It had been unstageable prior to lookback but was stage 4 in lookback.
F329 unnecessary drugs
failed to monitor for effectiveness, side effects, interventions and behaviors for Seroquel on two residents. Seroquel with inadequate reason for one resident.
F356: Didn't post staffing per requirements
Judy's opinion on this one: These MDS citations suggest to me that they may have been copying and pasting previous MDSs without verifying accuracy for lookback
THIS IS THREE VIRGINIA SURVEYS NOW. WE ARE LOOKING FOR TWO MORE THEN WE ARE DONE FOR THIS FY. IF ANYONE KNOWS OF THE OTHER TWO, PLEASE LET ME KNOW.
Thursday, August 27, 2015
Report of an MDS/Staffing Focused Survey
This is a report of an MDS Focused Survey from the Aanac list serve. This is one person's experience. Her advice is just that, and not all of her advice is based in regulatory requirements. I am printing this for the walk through of her experience:
They walked into the facility and got right to it. One of them went out on the floor with the MDS Coordinator while the other spoke with the DON/Administrator. They handed out the letter to the administrator (found on AANAC, I believe).
-They didn't hand out any surprises. What is available on AANAC is what they handed to us. They did request that the MDS Worksheet be handwritten. They wanted a policy for each column on the worksheet (except Skilled, LTC, Extensive Asist of Two). We didn't have a policy for UTIs, but the Infection Control policy was given instead and they "were fine with it" per the DON.
- The "Extensive Assist of Two" column - the MDS Coordinator went by the resident's most recent MDS.
- They wanted to know why Sig Changes were done, so if you're not noting the reasons why in the nurse's notes, I'd suggest starting...
- Overall, they weren't *as* focused on the MDS as I'd thought they would be. They zeroed in on psychotropics and catheters, making sure each resident had documented justification for the catheter, making sure dose reductions and behaviors were documented for the psychotropics.
- They did ask specifically (per the MDS Coordinator) for "MD Documented Behaviors" for residents on psychotropics. In this case, the MDS Coordinator was able to find an MD progress note that did document on behaviors. But honestly, I've not heard of any requirement that the MD documents on behaviors....usually it is the nurse who documents on the behaviors, sends that fax to the MD, and s/he decides what to do. So, we'll have to start doing something different in all of our facilities. This was not an issue at all with the regular state survey we had at a different facility last week.
- Remember that per current best practices, foley caths should be changed PRN, not monthly. If the MD orders otherwise, we should educate the MD as to current best practices, and the MD can decide what to do.
- Make sure that if a resident has a catheter, any pertinent diagnosis are captured in Section I.
- They did watch some pressure ulcer dressing changes. They were very happy with weekly wound documentation, which clearly shows the wound progress.
- This may not even be worth mentioning, it was just a hunch the MDS Coordinator got. The surveyors seemed to want to know how well the MDS Coordinator knew the CNAs. They asked her to go out on the floor and introduce them to CNAs, and they'd ask her, "Now what's her last name...?" Maybe they were just honest questions. But the MDS Coordinator said her radar went up. It "felt" to her like they wanted to make sure the MDS Coordinator had a relationship with the CNAs.
- Staffing was a big part of the survey. Per the staff, it felt like two different surveys - one was the MDS Focused Survey, the other was the Staffing Survey. The staff kept on trying to figure out the relationship between the two. But, nobody knows what that relationship is. Just make sure your staffing sheets and staffing ratio sheets are updated...
- I heard that for some MDS Focused surveys, the surveyors had obviously just learned the MDS process themselves. That was definitely NOT the case here.
- The surveyors were extremely kind and understanding, and I'm not just saying that on the offchance they are reading this ha. Coffee and rolls were provided to them, and they were appreciative of that. I only mention it because it's such a small gesture - why not do it? We did *not* do that with the surveyors we had in our facility last week, and the atmosphere was 100% different. I'm not saying coffee and rolls make all the difference, but I think it may play a small role in making them feel appreciated and welcome, rather than unwanted and in a hostile environment.
CMS adds new portal in QAPI webpage highlighting adverse drug events in NHs
Adverse Events in Nursing Homes
Office of Inspector General Report: Adverse Events in SNFs: National Incidence among Medicare Beneficiaries
In February 2014, the Office of Inspector General (OIG) released its report Adverse Events in SNFs: National Incidence among Medicare Beneficiaries. It reported that one in three skilled nursing facility (SNF) beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their skilled stay. The OIG determined that nearly 60 percent of those events were preventable.
Potentially Preventable Adverse Events in Nursing Homes
In its report on adverse events, the OIG recommended that CMS collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop and promote a listing of potential events that occur in nursing homes to raise awareness of adverse events that harm to nursing home residents. Using the OIG study, CMS and AHRQ worked together to create a list of the most common potentially preventable adverse events.
Click here to access a listing of Potentially Preventable Adverse Events
Adverse Drug Events in Nursing Homes
Adverse Drug Events in Nursing Homes
Of all the events identified in the OIG report, 37 percent were related to medication. The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death.
These findings are further supported by Propublica data reported in a recent Washington Post article which stated, “…from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin. It is clear that adverse events related to high risk medications continue to be pervasive with devastating effects to nursing home residents.
These findings are further supported by Propublica data reported in a recent Washington Post article which stated, “…from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin. It is clear that adverse events related to high risk medications continue to be pervasive with devastating effects to nursing home residents.
During its collaboration with AHRQ, CMS began work to develop and test a Focused Survey on Medication Safety Systems that looks at nursing home practice around high-risk and problem prone medications, such as warfarin. One of the foundational tools for the survey grew from the listing of potentially preventable adverse events. CMS envisions this tool as a resource document containing necessary information for evaluating high risk medications. It was designed to be a crosswalk that lists:
- common potentially preventable adverse drug events
• risk factors related to those events,
• triggers – signs, symptoms, or clinical interventions which could indicate that the adverse drug event has occurred, and
• probes which would assist surveyors in evaluating systems around high risk medications.
Adverse Events Tools and Resources
CMS will add resources and tools as they become available, which may assist nursing home providers to identify, track, and systematically investigate adverse events that have occurred; as well as develop and implement systemic interventions that will help prevent adverse events.
- Page last Modified: 08/25/2015 11:18 AM
Updated Information for Payroll Based Journal
August 27, 2015
Updated Information for PBJ Electronic Staffing Data Submission
The following documents are now available in the “Downloads” section below:
- “PBJ QTSO Registration and Training 8-4-15”: Instructions on how to register for voluntary submission and other PBJ training information. Registration is OPEN and ALL Long-term Care facilities are encouraged to register for the voluntary submission period beginning October 1, 2015.
- “PBJ Policy Manual DRAFT (V1.1) 8-25-15”: The draft policy manual has been updated to reflect recent changes to submission guidelines. Changes are indicated in red text.
- “PBJ Policy Manual FAQ 8-25-15”: A list of frequently asked questions and answers about PBJ instructions and policies.
- PBJ QTSO Registration and Training 8-4-15 [PDF, 77KB]
- PBJ Policy Manual Draft (V1.1) 8-25-15 [PDF, 845KB]
- PBJ Policy Manual FAQ 8-25-15 [PDF, 99KB]
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