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Survey Prep: 4 Steps NACs Should Take And Why They’re Needed

By Caralyn Davis, Staff Writer - February 28, 2018

With the MDS Focused Survey gone, the MDS no longer has its own private survey process, points out Michelle Synakowski, LNHA, RN, DNS-CT, RAC-MT, vice president of health services for Community Wellness Partners in Clinton, NY. “However, the MDS and the Resident Assessment Instrument (RAI) now have been incorporated into the whole Long-term Care Survey Process (LTCSP) for every surveyor.”


With the MDS, the care area assessments (CAAs), and the care plan all playing key roles in the LTCSP, nurse assessment coordinators (NACs) should consider taking the following four steps based on the survey process that the Centers for Medicare & Medicaid Services (CMS) has established:


1. As always, prioritize MDS accuracy


“When you look at the new survey process, you have to start with how surveyors choose the resident sample,” says Synakowski. “The MDS is at the center of that whole process.”


The LTCSP Procedure Guide walks through all seven components of the survey process: 1) offsite preparation; 2) facility entrance; 3) initial pool process; 4) sample selection; 5) investigation; 6) ongoing and other survey activities; and 7) potential citations. But when surveyors arrive at the facility, the basic resident-centered process works like this:


·         Surveyors briefly screen all facility residents.

·         Surveyors then develop a smaller initial pool of residents and conduct a deeper screen on them, guided by the Resident Interview, Resident Observations, Resident Record Review, and Resident Representative Interview Care Areas and Probes in the LTCSP Initial Pool Care Areas zip file.

·         Surveyors select the final resident sample from the initial pool for in-depth investigations.

·         Surveyors conduct in-depth investigations on residents in the resident sample using both the Critical Element Pathways and the investigative protocols in Appendix PP of the State Operations Manual, as well as conducting mandatory and triggered facility tasks (i.e., systems-focused investigations), an unnecessary medication review, and closed record reviews of discharged residents involving unexpected death, hospitalization, and community discharge.


The initial pool includes both offsite-selected residents and onsite surveyor-selected residents:


·         Offsite-selected residents will include residents preselected based on MDS data and up to five residents (across the entire survey team) named in a complaint or facility-reported investigation involving mistreatment, abuse, neglect, injuries of unknown origin, or misappropriation of property.

·         Onsite-selected residents may include newly admitted residents admitted in the last 30 days; vulnerable residents (e.g., residents who are dependent on staff and at high risk for care concerns, such as a resident with dementia or a quadriplegic resident); and residents with other serious identified concerns (e.g., a resident who is yelling out in pain or who has significant bruising on their face).


“At the start of the survey, the offsite-selected residents chosen based on MDS indicators make up 70% of the expected sample size,” notes the LTCSP Procedure Guide. “Once onsite, surveyors do not need to consider maintaining a 70/30 split between offsite- and onsite-selected residents; the focus is on identifying residents for the initial pool and sample based on concerns.”


CMS hasn’t released details about how the MDS indicators are calculated. However, there are 32 MDS-based clinical indicators assessing the following concerns:


· Alzheimer’s or Dementia

· Anticoagulant with Internal Bleeding

· Anticoagulant without Internal Bleeding

· Bowel & Bladder

· Catheter with UTI

· Catheter without UTI

· Constant Pain

· Decline in ADLs

· Dehydration

· Depression

· Dialysis

· Falls with Major Injury

· Feeding Tube / NO Dehydration

· Feeding Tube with Dehydration

· Four (4) or More Re-Hospitalizations

· Frequent Pain

· Hospice

· Insulin

· Major Infections

· One (1) Re-Hospitalization

· Preadmission Screening and Resident Review (PASARR)

· Pressure Ulcers Facility Acquired

· Pressure Ulcers Worsening

· Restraints

· ROM Limitation / NOT Receiving Therapy

· ROM Limitation / Receiving Therapy

· Tracheostomy

· Two (2) or Three (3) Re-Hospitalizations


· Ventilator

· Wandering

· Weight Loss


These indicators are presented to surveyors in two ways to help them develop and finalize the resident sample:


·         The Facility Rate Report. This report provides a facility-level picture of how many residents and which MDS indicators are potential concerns. The report looks at all 32 MDS-based clinical indicators. It lists the total number of MDS assessments included in the report, the number of residents with each indicator, and the percent of residents with each indicator. See a sample MDS Indicator Facility Rate Report here.

·         Offsite-selected residents list. This list drills down to the resident level, giving surveyors the list of offsite-selected residents (complete with MDS-provided room numbers) and their MDS indicators. Note: Providers don’t have access to either of these documents.


In addition to using MDS indicators as a component of sample selection, surveyors also use the MDS during the in-depth investigations of care areas, following detailed guidance in the Critical Element Pathways that “specifically directs surveyors back to the MDS,” says Synakowski. “The Critical Element Pathways all start out with: Is the MDS accurately coded?” For example, the Pain Recognition and Management Critical Element Pathway (form CMS-20076) instructs surveyors to review the following MDS sections, as well as physician’s orders, pertinent diagnoses, and the care plan, to guide their observations and interviews:


Review the most current comprehensive and most recent quarterly (if the comprehensive isn’t the most recent) MDS/CAAs for Sections C – Cognitive Patterns, G – Functional Status, J – Health Conditions, K – Swallowing/Nutritional Status, L – Oral/Dental Status, N – Medications, and O – Special Treatment/Proc/Prog - dialysis (O100J) or hospice (O100K).


“Given the role that the MDS plays throughout the survey process, MDS data accuracy, including appropriate diagnosis coding, is so important,” says Synakowski. “Facilities need to have some type of quality assurance process that ensures the accuracy of MDS data. For example, providers would want to make sure that the dementia diagnosis is coded appropriately on residents who have dementia—that you aren’t just giving them a diagnosis of dementia because they were confused at some point. There needs to be documentation that supports a diagnosis of dementia.”


Providers should audit at least 10 percent of their MDSs every month, recommends Synakowski. “They also need to determine whether they want an internal or external auditor to do that. Sometimes doing both is beneficial: looking at your process internally and then bringing in someone periodically to do an external audit as well.”


2. Check MDS assessor competencies


“A key concept in the new survey process is competency,” notes Synakowski. “This means skills competency for nurses and nurse aides, but also making sure that the person who is assessing the resident on the MDS in a particular care area is competent to do that assessment. Surveyors will make sure that the MDS sections are completed by the appropriate discipline.”


This can happen in two ways:


1)      During Care Area reviews of individual residents. The Critical Element Decisions section of most Critical Element Pathways includes a question that targets the competency of MDS assessors. For example, the sixth Critical Element Decision in the Activities of Daily Living (ADL) Critical Element Pathway (form CMS-20066) asks:


Did staff who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident’s status, needs, strengths and areas of decline, accurately complete the resident assessment (i.e., comprehensive, quarterly, significant change in status)?


2)      During the Resident Assessment triggered facility task. The first Critical Element Decision in the Resident Assessment Critical Element Pathway (form CMS-20131) asks the exact same question as the above ADL Critical Element Pathway. Two circumstances will trigger this task:

a.       The survey team identifies a delay with the completion and/or submission of assessments. This delay typically is discovered offsite due to problems compiling the Facility Rate Report and the offsite-selected residents list.

b.      During the initial pool process, surveyors identify MDS discrepancies for care areas they didn’t note for further investigation. What’s an MDS discrepancy? The LTCSP Procedure Guide offers this example: “MDS says the resident has pain and the resident says he/she has never had pain or the resident has a contracture but the MDS doesn’t have it marked.”


In both the Care Area reviews and the Resident Assessment facility task, a “no” answer by the surveyor to this skills/qualification question will result in a citation under F641 (Accuracy of Assessments).


3. Focus on the CAAs


“In some areas of the United States, there hasn’t always been a significant focus on the CAAs. During trainings, sometimes nurses have said to me, ‘Nobody ever looks at the CAAs, so we don’t pay much attention to them,’” says Synakowski. “However, CMS has realized that the CAAs drive a really good care plan, so the survey process now has an increased focus on using the CAAs to make individualized care planning decisions and improve goal setting.”


It’s important to note that the Critical Element Pathways direct surveyors to include the CAAs as part of the MDS review that will help guide observations and interviews. For example, the Hydration Critical Element Pathway (form CMS-20092) tells surveyors:


Review the most current comprehensive and most recent quarterly (if the comprehensive isn’t the most recent) MDS/CAAs for Sections C - Cognitive Patterns, G - Functional Status, J – Health Conditions-Problem Conditions (J1550), K – Swallowing/Nutritional Status, L – Oral/Dental Status, N – Medications, and O – Special Treatment/Proc/Prog-Hospice (O0100K) or dialysis (O0100J).


Some Critical Element Pathways also go a step further to include the CAAs as part of the Record Review section. For example, the Record Review section of the Nutrition Critical Element Pathway (form CMS-20075) includes the following first step:


Review the MDS and CAAs, nursing notes, nutritional assessment and notes, rehab, social service, and physician’s progress notes.

o Have the resident’s nutritional needs been assessed (e.g., calories, protein requirement, UBW, weight loss, desired weight range);

o Was the cause of the weight loss identified; and/or

o Is the rationale for chosen interventions or no interventions documented?


4. Check care plans for person-centered care


“Instead of developing a comprehensive care plan to meet the individual needs of the resident, many providers in the past focused on ‘What do I have to put in the care plan so I don’t get cited on survey?’” notes Synakowski. “The new regulations force providers to be very person-centered. CMS uses the terminology ‘locus of control,’ which basically means that the care plan should show that the resident is making their own choices and that they have control over their daily lives.”


So NACs need to ensure that the choices fit the resident’s center of focus and the control is in the resident’s center of focus, says Synakowski. “The care plan shouldn’t just list what you are doing to the resident. It should address what the resident is requesting to have done to help accomplish their goals, incorporating both personal and cultural preferences.”


NACs also should make sure that the facility has set up processes to meet the requirements for resident rights related to care planning, says Synakowski. In addition to providing the resident or representative with an up-to-date baseline care plan by completion of the comprehensive care plan, facilities must have processes in place that ensure residents know about—and have the ability to access—the following rights:


·         To choose who they want to participate in the comprehensive care planning process. “It can be them, but even if they are capable, they have a right to identify another person who would do that on their behalf,” says Synakowski.

·         To request a meeting or a revision of the care plan at any time.

·         To participate and establish goals and outcomes, to see the care plan, and to sign off on it after any significant changes in the care plan.


These reviews are needed because the Critical Element Pathways now have a much greater focus on resident involvement, resident choice, resident control, says Synakowski. For example, the Pressure Ulcer Critical Pathway (form CMS-20078) includes the following questions designed to determine resident involvement, resident choice, and resident control involving the treatment of pressure wounds:


Resident, Resident Representative, or Family Interview:

¨ Did your wound develop in the facility? If so, do you know how it occurred?

¨ Has staff talked to you about your risk for the wound and how they plan to reduce the risk?

¨ How are they treating your wound?

¨ Is the wound getting better? If not, describe.

¨ How has your wound caused you to be less involved in activities you enjoy?

¨ How has your wound caused a change in your mood or ability to function?

¨ How did the facility ensure you had a choice in how your wound would be treated?

¨ How often are dressings changed or treatment applied?

¨ Does your wound hurt? Do you have pain with wound care or when the dressings are changed? If so, what does staff do for your pain?

¨ What types of interventions are done to help heal your wound? Ask about specific interventions (e.g., positioned q2h, use of pressure redistribution devices or equipment).

¨ If you know the resident refused care: Did staff provide you with other options of treatment or did staff provide you with education on what might happen if you do not follow the treatment plans?


Staff Interviews (Nursing Aides, Nurse, DON, Attending Practitioner):

¨ How did you involve the resident in decisions regarding treatments?


Record Review:

¨ Was a comprehensive care plan developed? Does it address identified needs, measurable goals, resident involvement and choice, and interventions to heal/prevent pressure ulcers (e.g., pressure relief devices, treatment, and repositioning)? Has the care plan been revised to reflect any changes in PU?


Additional steps


Other steps Synakowski recommends NACs take include the following:


·         Make sure that Significant Change in Status assessments (SCSAs) are completed as appropriate.

·         Check that the PASARR recommendations are incorporated into the comprehensive care plan.

·         Double-check that MDSs are completed timely and submitted timely into the QIES ASAP system.

·         Make sure baseline care plans utilize all available paperwork, incorporating the discharge summary from the hospital, the history and physical provided by the hospital, and the physician admission orders, as well as any results from risk assessments that were completed by the facility.

·         Help do a final review of the record while completing that MDS process to ensure that everything is accurate and based on an assessment of the resident.

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