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4/20/2015 MDS Documentation LeadingAge Iowa Part 1 May 7, 2015 12:30‐1:30pm Part 2 May 7, 2015 1:45‐2:45pm Marilyn Mines, RN, BC, RAC‐CT Senior Manager of Clinical Services FR&R Healthcare Consulting, Inc. Frost, Ruttenberg & Rothblatt, P.C. 111 S. Pfingsten Road, Suite 300 Deerfield, IL 60015 [email protected] Main: (847) 236‐1111 or (888) 377‐8120 Direct: (847) 282‐6416 ©2015 FR&R Healthcare Consulting, Inc. 2 1 4/20/2015 OVERVIEW ©2015 FR&R Healthcare Consulting, Inc. 3 Documentation • Verbal Picture of the Resident • Treatment and care plans, proof of implementation • Clinical judgment, expertise, and decision making • Resident’s response to interventions and treatments ©2015 FR&R Healthcare Consulting, Inc. 4 2 4/20/2015 Legal Ramifications Survey Deficiencies Inefficient Operations Compliance Issues Lack of Supportive Documentation Care Issues Reimbursement Issues Investigatory issues ©2015 FR&R Healthcare Consulting, Inc. 5 Regulations Federal The word “documentation” is mentioned throughout Appendix PP of the State Operation Manual Every area of care that is reviewed during the survey process is corroborated with documentation in the clinical record ©2015 FR&R Healthcare Consulting, Inc. 6 3 4/20/2015 Regulations Medicare To be considered a skilled service, the service must be so inherently complex that it can safely and effectively be performed only by, or under the supervision of professional or technical personnel skilled, then the documentation must reflect medical complications that require the provision of the service by skilled personnel ©2015 FR&R Healthcare Consulting, Inc. 7 Regulations State Clinical records must be maintained in accordance with accepted professional standards and practices ©2015 FR&R Healthcare Consulting, Inc. Progress notes Services provided Plan of care 8 4 4/20/2015 Regulations State Accurate documentation to support CMI for Medicaid reimbursement ©2015 FR&R Healthcare Consulting, Inc. 9 Documentation Musts Documentation must be pertinent to the resident’s condition. I.E. support the services that contribute to the Medicare/ Medicaid reimbursement or private charges – Shortness of breath – Lesions and/or surgical sites – ADL needs – Fever – Behaviors – Cognition – Vomiting ©2015 FR&R Healthcare Consulting, Inc. 10 5 4/20/2015 Documentation Musts Indicate residents’ response to various interventions – – – – – – – Radiation Dialysis Tube feeding IV therapy Isolation Restorative programs Vent/respiratory services – Tracheostomy care ©2015 FR&R Healthcare Consulting, Inc. 11 Documentation Musts Indicate the circumstances regarding the situation – – – – – – Behaviors Delusions Hallucinations Wandering Rejection of care Indicators of depression ©2015 FR&R Healthcare Consulting, Inc. 12 6 4/20/2015 Documentation Musts • Be accurate – do not assume you know what is happening with the resident behind closed doors • Don’t document anything not witnessed by the writer or another staff/ family member witnessed and reported ©2015 FR&R Healthcare Consulting, Inc. 13 Consistent Documentation is Critical What if the resident's condition fluctuates from day to day, shift to shift? ©2015 FR&R Healthcare Consulting, Inc. 14 7 4/20/2015 Documentation is Critical • Clearly date and time stamp entries • Care plan must indicate the differences exhibited by the resident throughout the day – Why they occur – What the interventions are to improve or manage the differences ©2015 FR&R Healthcare Consulting, Inc. 15 Consistent Documentation is Critical Ensure that any new or changed conditions are documented consistently between shifts and disciplines E.g. monitoring after change in mental status, effects of new medication, carry‐over from therapy ©2015 FR&R Healthcare Consulting, Inc. Re. Medicare: Demonstrates skilled level of care through interdisciplinary management, monitoring and interventions 16 8 4/20/2015 Inconsistencies Resident is receiving gait training exercises with PT Nursing note: Resident ambulates without assistance. To ensure the compliance and proper reimbursement, any clinical need must be documented to address the services rendered as well as the resident’s response to them ©2015 FR&R Healthcare Consulting, Inc. 17 Conflicting Documentation: MDS • Section K1000 Swallowing/Nutritional Status indicates no – Loss of food/liquids from mouth – Holding food in mouth – Coughing/choking when swallowing – Difficulty or Pain • Section K05000 indicates no mechanically altered diet ©2012 FR&R Healthcare Consulting, Inc. 18 9 4/20/2015 Conflicting Documentation: Notes & Care plan • There is no documentation by nursing or the physician of any cognitive deficit or swallowing problem • There is no care plan indicating any type of fluctuation in swallowing issues or cognition • The CAA for Cognitive loss is not triggered ©2012 FR&R Healthcare Consulting, Inc. 19 Conflicting Documentation: Therapy • Speech pathology is seeing this resident daily for dysphagia and cognitive deficits ©2012 FR&R Healthcare Consulting, Inc. 20 10 4/20/2015 Documentation Includes orders for all services rendered Therapy orders prior to the actual evaluation Medications Treatments/Interventions Diet Must be legible Properly corrected and amended ©2015 FR&R Healthcare Consulting, Inc. 21 Reimbursement Documentation Supports services rendered Supports reimbursement paid Must be individualized to the resident and his/her needs ©2015 FR&R Healthcare Consulting, Inc. 22 11 4/20/2015 On‐going Documentation: Therapy Notes must support the need for therapy services Nursing notes must not contradict the need for therapy services Notes must clearly indicate the nature of the services being rendered ©2015 FR&R Healthcare Consulting, Inc. 23 Medicare Documentation Must support the need for skilled nursing or rehabilitation services on a daily basis! ©2015 FR&R Healthcare Consulting, Inc. 24 12 4/20/2015 • Consider the likelihood of change in the resident’s condition that requires the expertise of the skilled nurse or therapist Skills • Not all observations and assessments are skilled Possible change Observations Observation and Assessment • Skills that are required to identify and evaluate the need for modification of treatments until the resident has stabilized ©2015 FR&R Healthcare Consulting, Inc. 25 Observation and Assessment • Coverage may continue as long as there is a reasonable probability for a complication or an acute episode – ‘Reasonable probability’ ‐ a potential complication or further acute episode is a likely possibility ©2015 FR&R Healthcare Consulting, Inc. 26 13 4/20/2015 Management and Evaluation • The development, management, and evaluation of a patient care plan is only considered a skilled service when a technical or professional person’s skill are required to meet the resident’s needs and promote healing, recovery and safety • Not all planning and management requires skilled personnel ©2015 FR&R Healthcare Consulting, Inc. 27 Teaching and Training Must be conducted by a technical or professional person Self‐administration of injectable or complex medications, newly diagnosed diabetic (insulin, diet, foot‐care) Self‐ administration of nebulizers /inhalers Gait training/prosthetic care, care of braces, splints, orthotics ©2015 FR&R Healthcare Consulting, Inc. 28 14 4/20/2015 Teaching and Training Must be conducted by a technical or professional person Care of recent colostomy or iliostomy; self catheterization Self administration of G‐tube feedings; caring for central lines Care of dressings/skin treatments ©2015 FR&R Healthcare Consulting, Inc. 29 Direct Skilled Nursing Services Central or peripheral intravenous therapy; pressure ulcer management Tube feeding (meeting requirements); nasopharyngeal and Tracheostomy suctioning Respiratory therapy treatments; wound management; care of colostomy during early post‐op period in the presence of complications Nursing rehab including teaching and adaptive aspects of nursing ©2015 FR&R Healthcare Consulting, Inc. 30 15 4/20/2015 Direct Skilled Rehabilitation Services Must be related to an active written plan Level of complexity and sophistication that requires the judgment, knowledge, and skills of a qualified therapist Expectation of progress within reasonable predictable period of time Specific and effective treatment, reasonable and necessary for the patient’s condition ©2015 FR&R Healthcare Consulting, Inc. 31 On‐Going Documentation • Ensure that CNA staff is documenting ADLs and toileting patterns • Any change in the resident’s condition ©2015 FR&R Healthcare Consulting, Inc. 32 16 4/20/2015 COGNITIVE PATTERNS Section C: Cognitive Patterns Anytime the MDS item B8000 is NOT coded rarely or never, an interview must be attempted ©2015 FR&R Healthcare Consulting, Inc. 34 17 4/20/2015 Cognitive Impairment • Summary score from • Cognitive Performance the BIMS (C0200‐ Scale: when interview C0400) is not possible – Only if the interview – Based on the staff is conducted assessment and various sections on – C0500>9 the MDS ©2015 FR&R Healthcare Consulting, Inc. 35 Cognitive Performance Scale One of the following 3 situations exists 1. Coma B0100 and completely dependent in ADLs or ADLs did not occur (G0110A1, B1, H1, or I1 are 4 or 8) 2. Severely impaired cognitive skills (C0100=3) ©2015 FR&R Healthcare Consulting, Inc. 36 18 4/20/2015 Cognitive Performance Scale One of the following 3 situations exists continued 3. Two or more of the following impairment indicators are present Problem being understood (B0700>0) Short term memory loss (C0700=1) Cognitive skills problem (C1000>0) ©2015 FR&R Healthcare Consulting, Inc. AND 37 Cognitive Performance Scale One of the following 3 situations exists continued 3. continued AND One or more of the following severe impairment indicators are present Severe problem being understood (B0700>2) Severe cognitive skills (C1000>2) ©2015 FR&R Healthcare Consulting, Inc. 38 19 4/20/2015 INDICATORS OF DEPRESSION Depression Based on Total Severity Score • For the interview, (PHQ‐9©) Section D0200 is >=10 but not 99 • For the staff assessment, (PHQ9 OV©) Section D0600 is >=10 ©2015 FR&R Healthcare Consulting, Inc. 40 20 4/20/2015 Depression Documentation • If the resident cannot or does not answer the PHQ interview, staff documentation must be present to code the assessment accurately • Depression impacts several RUG categories but not all • Documentation is not only from nursing – all staff should be noting these signs/symptoms ©2013 FR&R Healthcare Consulting, Inc. 41 Depression Documentation: Interview • If a longer item was separated into its component parts during the interview, select the highest frequency rating that is reported • If the staff member has difficulty selecting between two frequency responses, code for the higher frequency ©2015 FR&R Healthcare Consulting, Inc. 42 21 4/20/2015 Depression Documentation: Assessment • If an assessment is needed, there must be staff documentation to accurately complete • All staff must be either be reporting or documenting indicators of depression that have been observed ©2015 FR&R Healthcare Consulting, Inc. 43 Depression Documentation: Assessment • If gathering information to complete this section involves talking to staff, interview all disciplines on all shifts • The frequency of clinical indicators must be documented with the date and time, as well as a description of the symptoms • Staff interventions, resident’s response, and indication of the observer must be indicated ©2015 FR&R Healthcare Consulting, Inc. 44 22 4/20/2015 Depression Documentation: Assessment • Encourage staff to report symptom frequency, even if the staff believes the symptom to be unrelated to depression • If the resident has been in the facility for less than 14 days, talk to family/significant other; review transfer records to inform the selection of a frequency code ©2015 FR&R Healthcare Consulting, Inc. 45 PHQ‐9© or PHQ‐OV© Little interest /pleasure in doing things Feeling or appearing down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy ©2015 FR&R Healthcare Consulting, Inc. 46 23 4/20/2015 PHQ‐9© or PHQ‐OV© Poor appetite or overeating Indicating that s/he feels bad about self, is a failure, or has let self or family down Trouble concentrating on things, such as reading the newspaper or watching television ©2015 FR&R Healthcare Consulting, Inc. 47 PHQ‐9© or PHQ‐OV© • Moving or speaking more slowly or being fidgety or restless, moving around more than usual • Thoughts that you would be better off dead, or of hurting yourself in some way • Being short tempered or easily annoyed PHQ‐ OV© only ©2015 FR&R Healthcare Consulting, Inc. 48 24 4/20/2015 BEHAVIORS Behavior Symptoms Documentation Descriptions, time, date, and the name of the staff observing any hallucinations, delusions, physical, verbal, or other behavioral symptoms; rejection of care or wandering How the behavior affected resident, staff, and/or others ©2015 FR&R Healthcare Consulting, Inc. 50 25 4/20/2015 Behavior Symptoms Documentation Interventions and residents' response Care plans must be descriptive with interventions to reduce a distressing symptoms ©2015 FR&R Healthcare Consulting, Inc. 51 ACTIVITIES OF DAILY LIVING 26 4/20/2015 ADLs • Must be accurate • The late loss ADLs – Bed mobility – Transfers – Eating – Toilet use • Impact every RUG category ©2015 FR&R Healthcare Consulting, Inc. 53 ADLs However All ADL activities must be documented to allow identification of resident needs The person completing the assessment must consider all episodes of the activity that occurred during the shift or each day of the 7‐day look‐back period ©2015 FR&R Healthcare Consulting, Inc. 54 27 4/20/2015 ADLs Must be signed or initialed by staff providing the ADL assistance Must be dates to authenticate the services during the look‐back period Whoever is completing the documentation should know the RAI definitions ©2015 FR&R Healthcare Consulting, Inc. 55 Recent RAI Updates Only staff that actually assists or observes the ADL activity should document Each episode over the 24/7 look‐back period must be utilized in the scoring Staff must know all the components of the activity ©2015 FR&R Healthcare Consulting, Inc. 56 28 4/20/2015 Per the latest RAI……. The responsibility of the person completing the assessment, …. is to capture the total picture of the resident’s ADL self‐performance over the 7‐day period, 24 hours a day (i.e., not only how the evaluating clinician sees the resident, but how the resident performs on other shifts as well). ©2015 FR&R Healthcare Consulting, Inc. 57 ADL Coding Each ADL has its own definitions, terminology, and components Each ADL must be coded independent of another Each episode that occurred during the 7‐day look back‐ period must be considered ©2015 FR&R Healthcare Consulting, Inc. 58 29 4/20/2015 ADL Coding Coding is based on what the resident actually does, not what staff thinks they could or should do Coding is not contingent on the use of adaptive equipment ADL self‐performance will vary throughout the day ©2015 FR&R Healthcare Consulting, Inc. 59 ADL Coding Definitions ADL Aspects • Various components of the activity ADL Self‐ Performance • Measures what the resident actually did ADL Support Provided • Measures the most support provided by staff ©2015 FR&R Healthcare Consulting, Inc. 60 30 4/20/2015 ADL ASPECTS ©2015 FR&R Healthcare Consulting, Inc. 61 Bed Mobility Positions body while in bed or alternate sleep furniture Moves to and from lying position How the resident ©2015 FR&R Healthcare Consulting, Inc. Turns side to side 62 31 4/20/2015 Transfers Includes to or from: bed, chair, wheelchair or standing position Moves between surfaces How the resident Excludes to and from bath/toilet ©2015 FR&R Healthcare Consulting, Inc. 63 Walking in Room or Corridor How the resident Walks between locations in his/her room Moves between ©2015 FR&R Healthcare Consulting, Inc. 64 32 4/20/2015 Locomotion on/off the Unit If in a wheel chair, self‐ sufficiency on in the WC How the resident Moves between locations in his/her room and adjacent corridor Moves returns to room from off‐unit locations ©2015 FR&R Healthcare Consulting, Inc. 65 Dressing Puts on, fastens and takes off all items of clothing How the resident Includes putting on and changing pajamas and house dresses Includes donning/ removing a prosthesis or TED hose ©2015 FR&R Healthcare Consulting, Inc. 66 33 4/20/2015 Eating Eats and drinks regardless of skill Includes intake of nourishment by any other means Does not include eating/ drinking during medication pass How the resident ©2015 FR&R Healthcare Consulting, Inc. 67 Toilet Use Does not include emptying Adjusts cloths Cleanses self after elimination Transfers on/off toilet Uses the toilet room, commode, bedpan or urinal How the resident Manages ostomy or catheter Changes pad ©2015 FR&R Healthcare Consulting, Inc. 68 34 4/20/2015 Personal Hygiene Includes shaving, applying makeup Includes shaving, washing/ drying face and hands Maintains personal hygiene Includes combing hair, brushing teeth How the resident Excludes baths and showers ©2015 FR&R Healthcare Consulting, Inc. 69 Bathing Takes a full‐ body bath/shower‐ includes sponge bath Excludes washing of back and hair How the resident ©2015 FR&R Healthcare Consulting, Inc. Transfers in and out of tub/shower 70 35 4/20/2015 ADL SELF‐PERFORMANCE ©2015 FR&R Healthcare Consulting, Inc. 71 Independent Supervision Resident completed activity with no help or oversight ©2015 FR&R Healthcare Consulting, Inc. Oversight, encouragement, or cueing 72 36 4/20/2015 Limited Assistance Resident was highly involved in activity. Received physical help in guided maneuvering* of limb(s) or other non‐ weight‐bearing assistance ©2015 FR&R Healthcare Consulting, Inc. 73 Extensive Assistance Resident performed part of the activity: weight‐bearing** assist was given ©2015 FR&R Healthcare Consulting, Inc. 74 37 4/20/2015 Who is Supporting the Weight? * Guided Maneuver – Resident – Staff may push or pull ** Weight Bearing – Staff – Staff lift or lower ©2015 FR&R Healthcare Consulting, Inc. 75 Total Dependence Resident did not perform any part of the activity ©2015 FR&R Healthcare Consulting, Inc. 76 38 4/20/2015 Other Codes Activity did not occur, or facility staff did not provide care 100% of the time Activity occurred only 2 times during the look‐back period ©2015 FR&R Healthcare Consulting, Inc. 77 Bathing Self‐Performance • • • • • • Independent‐no help provided Supervision‐oversight help only Physical help limited to transfer only Physical help in part of bathing activity Total dependence Activity did not occur ©2015 FR&R Healthcare Consulting, Inc. 78 39 4/20/2015 ADL SUPPORT PROVIDED ©2015 FR&R Healthcare Consulting, Inc. 79 No set‐up or Physical help from Staff Resident completed activity with no help or oversight ©2015 FR&R Healthcare Consulting, Inc. 80 40 4/20/2015 Setup Help Only Resident is provided with materials or devices necessary to perform the ADL independently e.g.. giving or holding out an item that the resident takes from the caregiver ©2015 FR&R Healthcare Consulting, Inc. 81 Physical Assist The resident was assisted by 1 staff person The resident was assisted by 2 or more staff persons ©2015 FR&R Healthcare Consulting, Inc. 82 41 4/20/2015 Activity Did Not Occur The activity did not occur or family and/or non‐facility staff provided care 100% of the time ©2015 FR&R Healthcare Consulting, Inc. 83 Bathing Support • Resident completed activity with no help or oversight • Set‐up help • One‐person physical assist • Two+ physical assist • ADL activity did not occur or family cared for the resident 100% of the time ©2015 FR&R Healthcare Consulting, Inc. 84 42 4/20/2015 Balance Must be completed for all residents During the 7‐day look‐back period, interdisciplinary team members should document observations of the resident during the 5 areas of transition Sitting to standing, Walking, Turning, Transferring on and off toilet, and Transferring from wheelchair to bed and bed to wheelchair (for residents who use a wheelchair). ©2015 FR&R Healthcare Consulting, Inc. 85 Balance If there is no documentation of the residents balance at least 1 time during the look‐back period The following process is required 1. Start by explaining the process to the resident Use assistive devices if used ©2015 FR&R Healthcare Consulting, Inc. 86 43 4/20/2015 Balance 2. Have resident stand up and keep the position for 3‐5 seconds This tests the transition of moving from a seated position 3. Have the resident walk 15 feet Rates walking transition ©2015 FR&R Healthcare Consulting, Inc. 87 Balance 4. Ask the resident to turn around This tests the turning transition 5. Have the resident go from the his room to the bathroom and prepare to toilet: taking down clothing, and sitting on toilet Rates moving on and off toilet ©2015 FR&R Healthcare Consulting, Inc. 88 44 4/20/2015 Balance 6. Ask the resident who using a wheelchair, to transfer from a seated position in the wheelchair, to a seated position on the be This tests the surface to surface transfers ©2015 FR&R Healthcare Consulting, Inc. 89 Balance Coding is based on whether the resident required physical assistance to balance, or not Not steady, required staff assist to stabilize Steady without any assistance from staff ©2015 FR&R Healthcare Consulting, Inc. Not steady but stabilized without staff assistance 90 45 4/20/2015 SECTION H BLADDER AND BOWEL Documenting Incontinence and Toileting Plan Must indicate how often the resident is incontinent Must indicate how often the resident is continent ©2015 FR&R Healthcare Consulting, Inc. Must indicate the resident’s response to a toileting program intervention 92 46 4/20/2015 ACTIVE DIAGNOSES RAI Definition of Active Diagnoses Physician‐documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7‐day look‐back period. ©2015 FR&R Healthcare Consulting, Inc. 94 47 4/20/2015 RAI Definition of Active Diagnoses Functional Limitations Loss of range of motion Nursing Monitoring Clinical monitoring by a licensed nurse Contractures, muscle weakness Fatigue, decreased ability to perform ADLs Serial blood pressure evaluations Medication monitoring Paresis or paralysis ©2015 FR&R Healthcare Consulting, Inc. 95 RAI Definition of Active Diagnoses Physician or extender must document that there is an active disease May specify the condition is active May indicate that the disease is uncontrolled and the treatment plan has to change ©2015 FR&R Healthcare Consulting, Inc. 96 48 4/20/2015 RAI Definition of Active Diagnoses If there is no specific documentation, the following will be used to confirm an active disease is present Positive test results resulting in a change in treatment Symptoms or abnormal signs Should be a notation of symptoms, change in orders for a condition, or limitations Notes regarding monitoring for therapeutic efficacy or for potentially severe side effects or abnormal signs ©2015 FR&R Healthcare Consulting, Inc. 97 RAI Definition of Active Diagnoses UTI has it’s own requirements‐all four must be met 1. Physician or extender has diagnosed a UTI within the last 30 days AND 2. Signs/symptoms of UTI AND 3. Significant lab findings documented AND 4. Current medication or treatment for UTI in last 30 days ©2015 FR&R Healthcare Consulting, Inc. 98 49 4/20/2015 DOCUMENTATION FOR ADDITIONAL ITEMS Oxygen Therapy • Why oxygen is needed • Manner of delivery/liter flow • When it is started and stopped • Respiratory assessments and treatments • Resident’s response ©2015 FR&R Healthcare Consulting, Inc. 100 50 4/20/2015 Restraints: Definition Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body (State Operations Manual, Appendix PP) ©2015 FR&R Healthcare Consulting, Inc. 101 Restraints: Definitions Remove easily: can be removed intentionally by the resident in the same manner as it was applied by the staff Freedom of movement: any change in place or position for the body or any part of the body that the person is physically able to control or access ©2015 FR&R Healthcare Consulting, Inc. 102 51 4/20/2015 Restraints: Definitions Medical symptoms/diagnoses: an indication or characteristic of a physical or psychological condition Consideration of objective findings of the resident’s subjective symptoms and medical diagnoses The nursing home must have exhausted alternative treatments and less restrictive measures before a physical restraint is employed ©2015 FR&R Healthcare Consulting, Inc. 103 Restraints Restraints do not treat the underlying causes of medical symptoms Must look , identify and address the physical or psychological condition causing the medical symptom If needed, may be used temporarily while the actual cause of the medical symptom is being evaluated and managed ©2015 FR&R Healthcare Consulting, Inc. 104 52 4/20/2015 Restraints A clear link must exist between physical restraint use and how it benefits the resident by addressing the specific medical symptom The medical symptoms that support the use of the restraint must be documented in the resident’s medical record, ongoing assessments, and care plans ©2015 FR&R Healthcare Consulting, Inc. 105 Restraints There also must be a physician’s order reflecting the use of the physical restraint and the specific medical symptom being treated by its use The physician’s order alone is not sufficient to employ the use of a physical restraint. CMS will hold the nursing home ultimately accountable for the appropriateness of that determination ©2015 FR&R Healthcare Consulting, Inc. 106 53 4/20/2015 Restraints The potential for a fall does not met the definition of a self‐injurious behavior or a medical symptom: this potential does not support the use of a physical restraint Isolation • • • • Why Care plan Not universal precautions Resident must be in a private room • Resident must not leave the room ©2015 FR&R Healthcare Consulting, Inc. 108 54 4/20/2015 Special treatments • Skilled therapy (PT, OT, ST) – Must be physician orders prior to evaluations being completed – Plan of treatment must be signed by physician – Prior to coding, all minutes, days, and the method of delivery must be documented by the therapist – If the MDS coordinator is coding the MDS, it is appropriate for she/he to see these records prior ©2015 FR&R Healthcare Consulting, Inc. 109 Special treatments • Skilled therapy (PT, OT, ST) ) continued – The therapy start date must be validated with the Plan of Treatment (POT) – The end of therapy date must be validated with the POT and orders – There must be validation that at least 15 minutes for each modality was delivered – Distinct days must be verified ©2015 FR&R Healthcare Consulting, Inc. 110 55 4/20/2015 Special treatments • Respiratory – There must be documentation of 15 minutes/day for each – The provider must be properly credentialed ©2015 FR&R Healthcare Consulting, Inc. 111 Diagnosis Driven Notes • Document toward the same 5 categories – Observation and assessment/management of treatment plan – Management/evaluation – Teaching/training – Direct Nursing Services – Direct Rehab Services ©2013 FR&R Healthcare Consulting, Inc. 112 56 4/20/2015 Diagnosis Driven Notes Cardiac and Pulmonary • Observation and assessment/management of treatment plan – Vitals, temperature and lung sounds – O2 saturation changes with exertion or function – Activities that promote shortness of breath and should be avoided – Medication changes – Need nasal cannula vs. mask use, nebs, suction, etc ©2013 FR&R Healthcare Consulting, Inc. Diagnosis Driven Notes 113 Cardiac and Pulmonary • Training/teaching – Pacing – Energy conservation – Diet compliance • Direct skilled nursing – Document why a licensed person is needed to manage the skilled need • Unable to participate in activity due to SOB or chest pain ©2013 FR&R Healthcare Consulting, Inc. 114 57 4/20/2015 DOCUMENTATION EXAMPLES ©2015 FR&R Healthcare Consulting, Inc. 115 Scenario 1 58 4/20/2015 Date/time Nursing Notes (sign all notes) 1/24/15 7‐3p NUTRITION: Adequate − Eats > 1/2 most meals. Eats 4 protein/day. Occ. refuses a meal, usually takes supplement ………………………… S. Bloom LPN Resident Name: Bob McGee • What does “most” mean? • What does “occasionally” mean? ©2015 FR&R Healthcare Consulting, Inc. 117 • Actual physician orders were –NPO, G‐tube –Jevity 1.2 cal 80cc/hr –Flush 100cc H2O Q6o ©2015 FR&R Healthcare Consulting, Inc. 118 59 4/20/2015 Scenario 2 Date/time Nursing Notes (sign all notes) 12/18 11‐7am Admission Warm, dry, flaky, edema, reddened SKIN PROBLEMS: Has open lesion(s) present in past 7 days. Scabs and healing wounds to left and right arm. Dressing to right and left buttock. Dressing to right foot and left leg. Dressing also on right heel. Scabs and healing wounds to left foot. FOOT PROBLEM/CARE: Has 1+ foot problem‐ eg. corn, callous, bunion, hammer toe, overlapping toe, pain, structural problem. Need Podiatrist evaluation ..Janet Black RN Resident Name: Bob McGee ©2012 FR&R Healthcare Consulting, Inc. 120 60 4/20/2015 Date/time Nursing Notes (sign all notes) 12/22 3‐11pm 4 days post admission 4 Stage 2 pressure ulcers: sacrum, left medial thigh, right ischium, and left posterior thigh: 1 Stage 3 pressure ulcer: 1 Stage 4 pressure ulcer: left hip: 4 Deep Tissue Injury: left lateral foot, inferior and superior, left bunion, and right Hallux 2 Non‐stageable: left posterior thigh and right medial heel……………..M. Brown RN Resident Name: Bob McGee ©2012 FR&R Healthcare Consulting, Inc. 121 Section M 5‐day MDS 3.0‐Bob McGee 0 0 2 2 4 4 ©2012 FR&R Healthcare Consulting, Inc. 122 61 4/20/2015 5‐day MDS for Bob McGee 0 4 4 1 1 4 4 ©2015 FR&R Healthcare Consulting, Inc. 123 Scenario 3 ©2015 FR&R Healthcare Consulting, Inc. 124 62 4/20/2015 MDS POS 3 unstageable pressure ulcers Treatment for 5 areas R hip Turning and positioning program L hip R heel Pressure relieving device on bed L buttock L heel ©2012 FR&R Healthcare Consulting, Inc. Area Notes 2:09pm 125 Notes 2:36pm R hip Sacral decub with deep tissue injury L hip Reddened R heel Yellow drainage 4.3x3.3x.3 epithelial tissue with drainage L buttock Reddened with 2 open areas 6.5x5.0x.01 necrotic L heel Blister noted 3x2x.1 necrotic, mottled ©2012 FR&R Healthcare Consulting, Inc. 126 63 4/20/2015 Contradictions • None are described as unstageable ulcers • The physician ordered for 5 areas, the MDS only indicates 3 • On the same day, descriptions are quite different by different recorders ©2012 FR&R Healthcare Consulting, Inc. 127 Missing Documentation • No tissue tolerance assessment • Turning and positioning this resident per the individualized need as assessed • Turning and positioning every 2 hours is indicated by the care plan intervention • The mattress utilized meets the requirements for pressure relief ©2012 FR&R Healthcare Consulting, Inc. 128 64 4/20/2015 Scenario 4 Scenario 4 x • There is documentation that the resident has shortness of breath upon ©2012 FR&R Healthcare Consulting, Inc. 130 65 4/20/2015 More Contradictions Nursing Therapy Functional limitation on one side in upper and lower extremity Range of motion within normal limits Neither the resident nor Resident is at a very high staff believe the resident is rehabilitation RUG capable of increased category independence ©2012 FR&R Healthcare Consulting, Inc. 131 Scenario 5 66 4/20/2015 Date/time Nursing Notes (sign all notes) 11/5/14 11‐7am Sleeping during last rounds. No complaints voiced………………………………. M. Smith RN 11/6/14 7‐3pm Up for breakfast and lunch. Ate well. O2 at 2/l via nasal cannula, no SOB. Family visiting and made aware of order for Foley Catheter. Urine clear. No c/o voiced. Confused…………………………M. Roth RN 11/6/13 3‐ 11pm O2 at 2 l, sats 97%, no SOB, Foley draining well …………………………….. B. Brown LPN Resident Name: Robert Kennedy ©2013 FR&R Healthcare Consulting, Inc. Date/time 133 Nursing Notes (sign all notes) 11/5/14 11:30p Asleep during rounds . O2 at 2l, though wheezing was noted. Attempted to have the res. wake up for a change of position, but could not awaken him. Propped a pillow under the left side and turned slightly onto side. Wheezing diminished slightly. Resp. 24………….S Smith RN Resident Name: Robert Kennedy ©2013 FR&R Healthcare Consulting, Inc. 134 67 4/20/2015 Date/time Nursing Notes (sign all notes) 11/6/14 3:00am Elevated head of the bed resulting in a cough and elimination of wheezing.. Positioning corrected since resident slid down…………………………………..S Smith RN 11/6/14 No further wheezing. Lung sounds clear after 6:30am IPPB treatment was given. Coughed up non‐ measurable amount of clear phlegm. No complaints voiced. 98 o‐88‐22. Oxygen continues at 2 l/cannula. …………..S Smith RN Resident Name: Robert Kennedy ©2013 FR&R Healthcare Consulting, Inc. 135 Scenario 6 ©2015 FR&R Healthcare Consulting, Inc. 136 68 4/20/2015 Ethyl Mermen • This resident had a hip repair on the left hip for a comminuted fracture • Orders include Partial weight bearing • PT daily for gait training • Surgical site care ©2013 FR&R Healthcare Consulting, Inc. 137 Date/time Nursing Notes (sign all notes) 12/11/14 7‐3 99,6 o‐100‐24, alert and oriented. Requires assist with all ADLs, Went to PT this morning. CO of severe hip pain. APAP given. Participated in activity programming. Ate well at both meals.‐‐‐‐‐C Cats RN 12/11/14 3‐11 Ate dinner well, with no complaints. Walked to and from dining room with rolling walker. No pain medication required. Assist in ADLs given prior to bed…………………O Katz RN 12/11/11‐7 Slept all night. No SOB or complaints voiced……………………………………P Piper Lpn Resident Name: Ethyl Merman ©2013 FR&R Healthcare Consulting, Inc. 138 69 4/20/2015 Date/time Nursing Notes (sign all notes) 12/11/12 7‐3 No complaints voiced after morning PT. At 2pm, c/o pain at the surgical site ‐ 2/10 intensity. Tylenol 650mg given: relief noted within 30 min‐‐‐C Cats RN Required extensive assist with transfers due to PWB status. However, was observed to be transferring self with full weight bearing. Reminded of PWB status and reviewed transfer techniques. Resident did understand why she must not bear full weight of the fractured side. Incision intact, aligned with no edema. Using rolling walker to walk to the dining room for dinner: posture & balance poor‐needed constant reminders not to bear full weight of the surgical side.‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐O Katz RN 12/11/12 3‐11 Resident Name: Ethyl Merman ©2013 FR&R Healthcare Consulting, Inc. 139 Scenario 7 70 4/20/2015 ADL Documentation Scenario 1/6/14 1/7/14 Bed mobility Indep. no asst needed Indep. no asst needed Transfers No help needed. Indep. No help needed. Indep. Eating Res. req. no asst. Res. req. no asst. Toilet use No asst. Indep. No asst. Indep. ©2013 FR&R Healthcare Consulting, Inc. 141 Scenario: ADL Coding in Section G Self Performance Support A B Bed Mobility 1 2 Transfer 1 2 Eating 0 1 Toilet use 0 1 ©2013 FR&R Healthcare Consulting, Inc. 142 71 4/20/2015 SUMMARY High Risk Areas • Know why the resident is covered by Medicare or falls into a particular RUG category • Document to support the residents needs • Ensure clear and accurate physician orders • Inconsistency in notes must be avoided or explained – Nursing/nursing – Shift /Shift – Nursing/therapy • Use of unacceptable abbreviations • Make sure the documentation makes sense ©2013 FR&R Healthcare Consulting, Inc. 144 72 4/20/2015 Documentation • Accurate ADLs and toileting patterns • Change in the resident’s condition • Behaviors – What/when/why – Intervention – Resident’s response – Impact on others ©2015 FR&R Healthcare Consulting, Inc. 146 73
