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Long-Term Care Survey Alert

Federal Initiatives:

USE THREE-PRONGED APPROACH TO PREPARE FOR DAVE

Published on Mon Jul 01, 2002

Are you ready for DAVE to start looking at your facility's minimum data sets?

That's what may happen when the Centers for Medicare & Medicaid Services' new Data Assessment and Verification (DAVE) initiative rolls out nationwide in 2003.

DAVE's centralized intelligence system will use protocols to flag MDS coding errors or patterns that may have compromised resident care and/ or payment integrity. CMS says the main focus of the DAVE initiative is to improve MDS accuracy. Even so, the DAVE contractor will report any resident health and safety issues that it uncovers to the state survey agencies, confirms Steve Pelovitz, director of CMS' Survey and Certification Group.

MDS and clinical experts suggest facilities can help "DAVE-proof" their facilities using the following three strategies.

  • Identify and confront any "unspoken" administrative pressure for nurses to code the MDS in a way that avoids triggering a quality indicator. "That's been one of the problems with the QIs right from the start," says Rena Shephard, a member of the CMS stakeholder group and president of RRS Healthcare Consulting in San Diego.

    "There is still a significant need for education in many facilities so that they manage resident care in a way that the QIs and quality measures are just afterthoughts," Shephard adds. "That happens when you know that your facility is providing good care and has the monitoring systems in place to signal a problem before it becomes a trend."

    For example, your facility should definitely have systems to catch unintended resident weight loss well before it triggers a QI.

    "The weight loss trigger under OBRA is a 5 percent loss in one month and 10 percent in six months," says Annette Kobriger, a long-term care nutritionist in Chilton, WI. "Yet, a resident who is underweight or does not quite meet the weight loss trigger and is eating poorly should be investigated" without delay.

  • Target areas where discrepancies commonly occur between the MDS and clinical documentation. For payment-related issues, Section G should be a major focus, as it can determine a resident's placement in higher-paying rehab and other RUGs.

    In the survey arena, pain (MDS Item J2) is becoming a hot issue, especially as the quality measures go into effect nationwide.

    Say the MDS coding shows the resident has moderate or mild pain but the medication administration record indicates the resident has received heavy doses of pain medications or complains of pain serious enough to interfere with normal activities. That kind of discrepancy would be a definite red flag for DAVE.

  • Review your documentation standards.

    "Even though CMS has made clear that the MDS is a source document, facilities must still follow accepted standards of practice and documentation," Shephard cautions.

    "For example, if you see a stage 1 pressure sore on a resident, you code on that on the MDS," she explains. "But the resident medical record should reflect a more in-depth assessment, timely notification of the physician, changes to the care plan and treatment orders." Documentation should also confirm that the plan of care has been implemented, with ongoing re-evaluation of its effectiveness.

    "If the MDS reviewers find pressure sores documented in the chart but not the MDS or vice versa, that's a problem," Shephard cautions.

    To stay on top of documentation and clinical issues, facilities can perform regular chart audits on a sample of residents with pressure sores, pain, weight loss and recent falls, as well as residents on intake and output, which signals hydration issues.

    "Go through the Kardex and medication administration record and look for people on pain management, including those taking scheduled medications for arthritis pain," suggests Karen Clay, a nursing consultant based in Webster, MA.

    Next, review the residents' medical records all the way from the assessment through the implementation and evaluation to see to see what kind of story they'd tell DAVE. If the answer is not what you'd hoped for, figure out if it's a clinical shortfall or a lack of proper documentation of care that does meet accepted standards.

    And remember: From surveyors' and Medicaid Fraud Control Units' perspectives, if it wasn't documented, it wasn't done.

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