Managing the facility's MDS system.

As we are used to by now in the long-term care industry, a lot of regulatory initiatives are being implemented all at the same time. Most imminently, facilities are facing a transition to electronic submission of the MDS by June 22.

Let's look at managing the MDS process from the standpoint of the whole facility. Most readers are probably intimately familiar with the sections, items and instructions for completing the actual assessment instrument. There are excellent reference manuals, local educational programs and experienced consultants who can help.

I suspect that the hardest part of implementing the MDS process since 1991 has been for facilities to analyze their organizational structures, assess staff capabilities and understand the resident admissions process to successfully manage the overall MDS system. This means that each resident's initial quarterly, annual and significant-changes assessments are completed on time, accurately and comprehensively; that all the appropriate staff are involved in the data collection process; and that the subsequent care-planning process is based upon the results of the MDS and includes residents and families.

How well is your facility organized to manage the MDS process? Do you have a designated MDS Coordinator? Is this person also responsible for actually completing the MDS for each resident, or does he or she truly coordinate all interdisciplinary efforts? Is this professional also responsible for coordinating the care-planning process? If you are an average 100-bed facility, this MDS Coordinator is completing an average of 7 MDSs for each of 135 residents each year (more or less, depending upon your average length of stay), for a total of 945 MDSs. Then, of course, the coordinator reviews each of 18 Resident Assessment Protocols (RAPs) for each MDS, decides which RAPs should be care-planned, schedules the meeting and oversees the completion of a detailed care plan.

You can see how difficult it is for a single MDS Coordinator to actually complete all the required MDSs. Successful facilities will assign most of the MDS items to be completed by staff who provide direct care for each resident, including the nurse, therapist, social worker, dietitian and activities professional, leaving the MDS Coordinator to truly coordinate. Involving direct care staff in completing the MDS is an important step in assuring the accuracy. and timeliness of MDS completion.

The next hardest part involves establishing a systematic process for measuring the information that must be reported in the MDS. Does your facility collect assessment data before answering the MDS items? I hope so, because it is difficult to report on the ADL status of a resident for seven days across all shifts unless someone is tracking it. Additionally, since the RUGS grouper assigns residents to different groupings, based in part on the ADL score, your facility risks not receiving sufficient reimbursement for the actual care required to help someone who is completely dependent upon the assistance of others for all ADLs. Is someone communicating with the therapy providers to make sure that therapy-screening assessments are performed immediately and that therapy modalities are started immediately upon admission? If not, then you won't have very many minutes to report on your MDS for the seven-day data collection period.

For example, if you begin to collect MDS data on the 4th day following admission, continuing through the 10th day, then finalize the assessment by the 13th day, you will be looking retrospectively at the services provided to the resident during this assessment period. But what if physical therapy didn't start until the 8th day of the resident's stay? You would only have three days of therapy services to record in the MDS.

Organizing the timing of your facility's assessment process is an important step in making sure that all MDSs can be electronically submitted in accordance with regulations.

Remember that the MDS is just what it says: a Minimum Data Set. This means that many residents will require additional assessments, including nutrition risk assessments, incontinence assessments, pressure sore risk assessments, restraint assessments and fall risk assessments. Many of the tools used for assessing these risks are also excellent data-collection tools for completing and updating the MDS. These tools should be completed and updated quarterly, prior to MDS completion, to ascertain whether a resident has experienced a change in condition. Look for commercially available assessment forms that integrate with the MDS and utilize the same definitions for specific items. This ensures that you are assessing residents consistently.

The staff assigned to perform these assessments should know each resident well, or the facility risks building a "house of cards" that can come tumbling down when inaccuracies are discovered. Remember, the MDS assessment process is formulated not only to be the foundation of the care plan and the subsequent care delivered, but to document the care actually reimbursed for by Medicare and many state Medicaid systems. Completing MDSs accurately is an important step in guarding against a criminal False Claims prosecution.

Finally, the thirty HCFA Quality Indicators are extracted directly from the MDS. A surveyor can review a summary of the number and percentage of residents in your facility who have certain characteristics, such as pressure sores, weight loss and incontinence, and then compare your facility's data with the statewide average. In states where surveyors already use quality indicator data to focus survey activity, facilities report that surveyors closely examine clinical areas that exceed the statewide average by as little as 5%. Completing MDSs accurately and consistently throughout the facility is an important step in knowing and-managing the information used in such Federal Medicare/Medicaid surveys.

Adapting the strategies discussed in this column may help manage the "unmanageable" - at least for now.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, OH. For further information, call [phone] or send correspondence c/o Nursing Homes/Long Term Care Management; fax [phone].