Data coded on the Minimum Data Set (MDS) is collected during structured and defined time periods; what happens with the resident outside of those time periods cannot be captured on the MDS and will not impact your quality measures (QMs) apart from hybrid QMs. Currently the antipsychotic QM is the only hybrid measure, and the falls with major injury long stay QM is anticipated to become a hybrid measure. Hybrid measures are calculated using MDS data as well as encounter data from other providers.
Information recorded on the MDS must be reproducible. “Reproducible” means that any auditor can review the resident’s health record and come to the same coding conclusion as is captured on your MDS. Regular review of QM data can reveal opportunities for overall facility process improvements that support MDS accuracy. These opportunities can include fine-tuning the training your staff needs for your resident population, evaluating the direct care you provide to your residents, and taking a close look at how you capture that care as data/information that is utilized for MDS completion. We are going to look at two often over-looked MDS-related reports that may help you start the process of improving your QMs.
MDS 3.0 NH Final Validation Report
One of the first and easiest reports to review flags for incomplete data that impacts QM calculations is found in the MDS NH 3.0 Final Validation Report. This report is generated with each batch of MDS assessments submitted to the Center for Medicare and Medicaid Services (CMS) through the Internet Quality Improvement & Evaluation System (iQIES). When reviewing this report, look for any Warnings – this is immediate feedback from CMS about some portion of each accepted MDS. You should also review Fatal Error messages, which indicate CMS was not able to accept the submitted MDS. Each Warning and Error is associated with an Error ID code, and the MDS 3.0 NH Validation Report will contain a brief overview of the problem; additional details for each Warning and Error ID code can be reviewed in the iQIES MDS Error Message Reference Guide.
Carefully review any MDS that is flagged with ID codes -3897 and -3908. These two codes are indicators that data is missing from a Medicare assessment QM item (the item was “dash coded”) in the accepted MDS. Since missing data impacts how the QM is calculated for this resident – either in how the QM itself is captured, or as an exclusion or a covariate for that QM – one incomplete data item (dash coded) on a Medicare assessment (the 5day PPS assessment and the PPS discharge assessment) reduces your facility compliance in the Skilled Nursing Facility Quality Reporting Program (SNF QRP). Reduced compliance for the SNF QRP MDS completion can lead to a 2% reduction in your Medicare Annual Payment Update (APU). Missing data on any MDS can impact your facility-level QM calculations.
A Fatal Error message indicates CMS could not accept the submitted MDS, and the information that caused the Fatal Error needs to be corrected. Assessments that are not accepted by CMS can impact your resident-level and facility-level QM calculations. If not corrected, these rejected assessments may have far-reaching effects on SNF QRP measures and Value Base Purchasing (VBP) measure calculations. These MDS can be reopened, and the information that caused the Fatal Error can be corrected. Once the Fatal Error is corrected, the MDS can be submitted.
Tracking missed data as reflected on the MDS 3.0 NH Final Validation Reports can help you identify weak areas in your data collection process; missed data can range from resident interviews to seemingly simple information such as a height or a weight not timely captured in the health record and therefore not coded on the MDS. Each item on the MDS has a purpose, and a large portion of the data captured on the MDS is utilized in some way to calculate QMs.
Conducting resident interviews has specific rules per the Resident Assessment Instrument (RAI) Manual, and CMS has included instructions on how to manage situations such as when residents are unable to complete an interview or refuse to be interviewed. Getting the non-interview data collected timely for the MDS has specific rules as well and is not a project to take lightly. If a consistent review of MDS 3.0 NH Validation Reports reveals a pattern of missed items, there is an opportunity to review facility policy that addresses how the required information (interviews and health data) is supposed to be collected in the health record.
The facility policy should align with the RAI manual instructions. A follow-up inquiry into why interviews are missed or data is missing in the health record may reveal problems in the process such as a lack of staff training, incorrectly scheduled data collection tools, or even data collection tools that are obsolete or do not address the current MDS requirements. This is also an opportunity to revise facility policy and implement a plan to capture the interviews and health information correctly in the resident’s record so it can be used on the MDS. Future auditing could include monitoring of the updated interview and data collection process in the health records as well as continued review of NH MDS 3.0 Validation Reports.
MDS 3.0 Facility Characteristics Report
The MDS 3.0 Facility Characteristics Report is created using MDS information submitted to CMS. When the report is pulled using the default date settings, the facility data in the report is up to date as of the prior Friday – this is almost real-time information about your resident demographic information. With consistent reviews of your MDS 3.0 Facility Characteristics Report, you can compare your facility percentages with the state and national average percentages. This can help to determine whether your facility’s demographic characteristics differ from the norm.
Facility characteristics may indicate a need to concentrate on a review of certain resident groups, including specific health needs and staff training to ensure your staff are providing adequate and safe care. For example, this report reflects resident sex distribution, age ranges, ethnicities and races, diagnostic characteristics including psychiatric diagnosis/intellectual disability/developmental disability, and hospice. Targeted staff training for specific resident populations can help reduce hospitalizations and re-hospitalizations; support behavior management; reduce the risk for falls, pressure injuries, and weight loss; and potentially reduce the risk for use of high-risk medications such as antipsychotic, hypnotic, antianxiety, and antidepressant medications. Well-trained staff can improve retention and staff satisfaction and may result in a far-reaching positive impact on the facility’s reputation.
Turning QM Data into Action
Your facility can take multiple steps to start the process of improving QMs:
- Review the MDS 3.0 NH Final Validation Report each time a batch of MDS is submitted, and track warnings and errors to determine if there is a trend in missed (dash-coded) MDS items.
- Carefully review any flagged MDS in this report, determine if the MDS was coded correctly, and investigate other causes of incomplete or missed data collection.
- Implement a plan and policies to support data capture per the RAI manual requirements.
- Conduct a monthly or quarterly review of the MDS 3.0 Facility Characteristics Report and ensure your staff has training that is reflective of the needs of your resident population. While this report is not all-inclusive of your resident population characteristics, it is a simple starting point to target and develop a plan to support staff in caring for your residents.
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