MDS Alert

CMS is realizing that facility self-reporting may not be the best option for monitoring data.

The Centers for Medicare & Medicaid Services (CMS) has relied on information recorded in the Minimum Data Set (MDS) to monitor the use of certain drugs in nursing homes. But several federal agencies, as well as the public, generally, have increased their scrutiny over nursing homes giving residents drugs that may be more convenient — for staff — than medically necessary for residents.

The Office for the Inspector General (OIG) released a report (see below), compiled under the direction of Brian Whitley, regional inspector general for evaluation and inspections for the Kansas City regional office, on antipsychotic drug use in nursing homes, and they found a lot of discrepancies in the information on the MDS versus Medicare claims. As a result of the report, the OIG recommends that CMS bolster its monitoring efforts by increasing its efforts in validating the information submitted in MDS assessments and using additional data.

See These Numbers

One of the major discrepancies the OIG found was diagnoses versus drugs. A schizophrenia diagnosis reported on the MDS means that that resident is excluded from CMS monitoring of antipsychotic medication use. However, the diagnosis reported on the MDS in many instances did not match the resident’s Medicare claims.

More than 98,000 residents have schizophrenia diagnoses, according to MDS records, but many don’t have the corresponding medical treatment. “Of those, 29,617 residents (30 percent) had no record of a schizophrenia diagnosis in any of their 2017 and 2018 Medicare Part A or B claims or Part C encounter data for visits, procedures, tests, or supplies. This means there was no evidence that these residents received care for the diagnosis that excluded them from being measured in the percentage of residents receiving antipsychotics,” the OIG report says.

The differing information on the MDS versus Medicare claims for these residents makes sense in only two ways: Either MDS nurses are filling out the MDS to include inaccurate schizophrenia diagnoses for residents (many of whom are receiving antipsychotic drugs, according to their Medicare claims), or residents who truly have schizophrenia are suffering from incomplete medical records and are not receiving the services they need beyond medication. Either way, there appears to be a significant loophole in the quality measure designed to monitor antipsychotic drug use in nursing homes.

Interestingly, this discrepancy was more common in certain nursing homes, with 52 nursing homes’ reporting showing differences in 20 percent (or more) residents’ MDS assessments versus claims data. The OIG noted that 78 percent of the nursing homes with inconsistent reporting are for-profit, even though only 69 percent of all nursing homes are classified as for-profit entities.

Expect More Scrutiny, Including From Surveyors

CMS acknowledges the problem and plans to step-up official scrutiny—though the agency defends its current validation processes, reframing the 5 percent discrepancy between MDS submissions and Medicare Part D prescription claims as “95 percent accuracy.”

“There have been notable reductions in the prevalence of antipsychotic medication use in long-term nursing home residents …. Between 2011 and the second quarter of 2020, the national prevalence of antipsychotic medication use among long-stay nursing home residents was reduced by 41 percent to 14.1 percent nationwide, with every state showing reduced rates,” said Elizabeth Richter, then acting administrator of CMS in an April response to the OIG’s recommendations.

Still, surveyors are looking out for evidence of antipsychotic drug use — and other clinically incorrect or dangerous use of other drugs as well.

In 2021, several facilities have been cited for Ftag 757 “Drug Regimen is Free from Unnecessary Drugs,” says Linda Elizaitis, RN, RAC-CT, BS, president and founder of CMS Compliance Group in Melville, New York.

Two incidents resulted in immediate jeopardy citations, including a resident who was prescribed antidiabetic medication but did not receive the concurrent monitoring as prescribed by a physician — resulting in an emergency room visit with a blood sugar reading of 700. Another facility was placed in immediate jeopardy after failing to monitor adequately residents receiving anticoagulants nor incorporate the medication usage in their care plans, resulting in at least one extensive, serious nosebleed.

Surveyors are also noting residents being prescribed antibiotics when their diagnoses or conditions do not call for antibiotics — or, in some situations noted by surveyors, even when circumstances are correct, the prescription is not.

Other facilities have been cited with this Ftag for misappropriate use of opioids and for mistakes in a drug regimen that lead to a resident receiving the same medication twice as often as prescribed. Surveyors have found these issues on both standard surveys and complaint surveys.

Ensure Documentation is Consistent

One major takeaway from the OIG report and surveyor citations is that facilities are running into issues when residents’ medical records are not consistently updated or maintained. A resident’s medical record is the narrative of their condition and care, and fudging diagnoses or neglecting to record sudden symptoms or monitor the resident’s condition can cause serious problems for the resident — and the facility, when these discrepancies are eventually unearthed.

Person-centered care plans are an important tool in keeping a resident’s care “straight,” and although it may seem like unnecessary and annoying busy work for the authors of the care plans, they’re a useful way to keep residents safe and facilities compliant, says Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA, MDS consultant, in Columbus, Ohio.

Resources: See the OIG report here https://oig.hhs.gov/oei/reports/OEI-07-19-00490.pdf.