Long-Term Care

Updates from the Las Vegas MDS 3.0 Train-the-Trainer conference

MDS 3.0 Insider, August 23, 2010

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The CMS MDS 3.0 Train-the-Trainer conference in Las Vegas came to a close August 13, leaving attendees with a wealth of information to use in their training efforts as the October implementation date rapidly approaches. Some highlights from the conference in Las Vegas are as follows:

  • CMS is working diligently to develop a hybrid RUG system to comply with the partial RUG-IV delay included in the healthcare reform law. However, CMS officials hope Congress will rescind this delay. On Wednesday, July 14, the House passed H.R. 5712, which would repeal the one-year partial delay of RUG-IV and allow CMS to implement RUG-IV in full on October 1, 2010. The Senate has yet to vote on H.R. 5712, also known as the Veterans’, Seniors’ and Children’s Health Technical Corrections Act of 2010.
  • CMS provided conference attendees with the case mix index sets E01 and E02 for RUG-IV. The chart containing this information is posted on the Resources page of MDSCentral.
  • CMS officials reiterated that the MDS 3.0 and the transition to this new assessment tool is a team effort. And that team not only includes nursing home and swing bed staff members, but everyone in the long-term care industry, including CMS. “I am proud to be a colleague of each and everyone of you in the room,” said Tom Dudley, MS, RN, of CMS’ Division of Chronic and Post Acute Care, Office of Clinical Standards and Quality.
  • CMS officials clarified that Item E0800, Rejection of Care, is meant to identify potential behavioral problems, not a rejection of care based on a choice made by the resident or on behalf of the resident by a family member or other proxy decision maker. Therefore, assessors should not include behaviors that are consistent with the resident’s values, preferences, or goals or behaviors that have already been addressed. Also, assessors should determine if the behavior is really meant to reject care and is a matter of resident choice. If a resident exhibits behavior that appears to communicate rejection of care, assessors should ask directly if the behavior is meant to decline or refuse care.
  • CMS also clarified that assessors should code wandering in Item E0900 even if the wandering has a purpose but is unrealistic. For example, a resident who gets up and walks around the facility because he thinks he needs to go to work may have a purpose in his mind. But since that purpose is unrealistic, it should be coded as wandering.
  • CMS plans to add algorithms used in the RAND study that were designed to determine if a diagnosis is active or inactive to an appendix in the RAI User’s Manual. CMS officials said they would format and post these tools on their Web site as soon as possible.
  • When conducting the resident pain interview, assessors should code based on the resident’s responses, regardless of pain management efforts in place. Some facilities are concerned that a resident may say he has no pain, but that is because he is receiving pain medications. CMS clarified that facilities do not need to justify their pain management efforts by saying that there is pain present. If there is no pain, it usually means that the facility’s pain management efforts are working. Also, facilities are worried that resident responses may not match up with staff documentation. For example, a resident may complain that his pain leads to trouble sleeping but the night staff has not observed any problems with his sleeping. When situations like this arise, facilities should look into the issue to determine why there is a discrepancy and address it, but it is okay to have information in the chart that is different from the resident’s response.
  • CMS is working to develop/modify the CARE tool to help improve transitions and communication of information between care settings, as well as prepare for a potential payment bundling system in the future.
  • CMS plans to publish a document that will list what item set should be used for each assessment type.
  • Largely due to comments raised during the April Train-the-Trainer conference, CMS plans to revise certain items and skip patterns of Section Q sometime in 2011. CMS will also be releasing a brochure to inform residents and families about the return to community questions and care options. CMS officials assured attendees that this brochure will be available before the October 1 implementation date.
  • CMS plans to post a Local Contact Agency point of contact list on their Web site sometime in September.
  • If asked, facilities must be able to prove that the Care Area Assessments (CAA) they used are expert endorsed or evidence-based. This requirement is consistent with F-tag 492 – services must meet professional standards of quality.
  • CMS plans to revise instructions for item A2400C in the RAI User’s Manual to replace references to the SNF Advanced Beneficiary Notice (ABN) with the generic notice.
  • Since RUG-IV looks at staff time needed for services, and not the cost of these services or items, facilities may get paid less when providing IV medications than they would if providing IV fluids, even though IV medications are more expensive that IV fluids. To address such issues, CMS is looking into a non-therapy ancillary add-on for IV medications, IV fluids, and tube feeding.
  • CMS officials clarified that the time spent transporting a resident to/from therapy does not count as set-up time. Neither does the time it takes getting a resident ready for therapy.
  • CMS officials clarified that the assessment reference date for an End of Therapy (EOT) Other Medicare Required Assessment (OMRA) must be one to three days after the last day of therapy when therapy would normally be provided in the facility. This should be based on the facility’s schedule for therapy services (i.e., therapy is available Monday-Friday or seven days a week), not based on the therapy schedule of a particular resident.
  • Starting October 1, SNFs must be reimbursed based on the RUG-IV system. However, the MDS 2.0 is not designed to generate a RUG-IV or hybrid RUG-III grouper, which will create a problem for assessments that span the implementation date. CMS officials said that they are “trying to work out ways to bill for both time periods with the least ambivalence, aggravation, and burden as possible.” However, this is all CMS officials would reveal during the conference and told attendees to tune into the RUG-IV provider calls in late August and early September for more information.


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