On January 18th, 2023, CMS announced they will be conducting off-site audits in nursing homes for assessment accuracy and coding of residents with a diagnosis of Schizophrenia. Along with auditing for appropriate diagnosis, the audits will review appropriate use of antipsychotic medications. 

What does this mean for nursing facilities?

CMS utilizes data regarding the use of antipsychotic medications in the Five-Star Quality Rating System. A diagnosis of schizophrenia excludes the residents from two Quality Measures related to antipsychotic use Percent of Residents Who Received an Antipsychotic Medication (long-stay) and the Percent of Residents Who Newly Received an Antipsychotic Medication (short-stay). 

According to QSO-23-05-NH, if CMS determines that a resident was erroneously diagnosed with schizophrenia or the resident’s diagnosis was inaccurately coded on the MDS, there will be a negative impact to the facility’s FiveStar Quality Measure Rating on Care Compare. 

      • Overall Quality Measure rating will be downgraded to one star for six months
      • Long-Stay Quality Measure rating will be downgraded to one star for six months
      • Short-Stay Quality Measure rating will be suppressed for six months
      • Long-Stay Antipsychotic Quality Measure will be suppressed for 12 months

How Does a Schizophrenia Audit Work?

Facilities will receive a notification letter indicating they were selected for the audit. The letter will provide the audit process and information regarding documentation needed for review. Facilities will have the opportunity during the audit to ask questions and clarifications. Once the audit is complete, the facility can discuss the findings with the CMS contracted auditor.  

If a facility discloses to the CMS contracted auditor that they have inaccuracies in coding and plan to correct the inaccuracies prior to an audit, CMS will consider a lower action related to the impact to their star rating 

The auditors are requesting documentation regarding when the resident first received the diagnosis of schizophrenia. Additionally, the auditors will review the MDS assessments from admission, the first MDS assessment in which schizophrenia was coded, and the most recent MDS assessment for the resident. Additional documentation for review may include an initial psychiatric evaluation, ongoing psychiatric care, antipsychotic medications, behavior signs, symptoms, and management.

What should nursing facilities be doing now?

Facilities should evaluate the residents in their facilities with a diagnosis of Schizophrenia for accuracy focusing on when the resident was first diagnosed. Determination should include if the resident was diagnosed prior to or after admission to the facility.  

If diagnosed after admission, does the resident have an initial psychiatric evaluation for the diagnosis of Schizophrenia? Facilities need to work with their psychiatric services and/or attending physicians to determine an accurate diagnosis of Schizophrenia was made, ongoing psychiatric treatments/services are in place, and management of signs and symptoms of the disease.  

The Nurse Assessment Coordinators (NAC) and the Interdisciplinary Team (IDT) in the facilities need to focus on accurate coding of Schizophrenia on the MDS, evaluation of the residents’ care plans for resident-specific interventions, supporting documentation for behaviors and/or signs and symptoms, and ongoing management of the diagnosis.  

Incorporating residents with a diagnosis of Schizophrenia and antipsychotic medication use into the facilities Quality Assessment and Performance Improvement (QAPI) program is a thorough way of monitoring documentation. The accuracy of the diagnosis of Schizophrenia can be reviewed along with the coding and required documentation for the residents.  

MDS Consultants understands the importance of quality of care in nursing facilities. We work with our clients in achieving compliance with the coding of Schizophrenia in Section I of the MDS. To assist them with being compliant, we offer an opportunity to review residents for accuracy of the MDS coding with residents who have Schizophrenia diagnosis. 

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