MDS Alert

Check out the latest round of revisions to the RAI user's manual. The Centers for Medicare & Medicaid Services had, at press time, just posted an April 2004 update to the manual, which can be accessed at www.cms.hhs.gov/medicaid/mds20/rai0404upd.pdf. The revisions include clarifications at K5a (parenteral/IV) directing providers not to include fluids administered solely as flushes when coding this item. In coding 01 (number of medications), do not include topical preparations used for preventive skin care (i.e., moisturizers and moisture barriers should not be coded there). Do include antigens and vaccines in coding this item.
 
CMS added the following language in directions for coding pain in Section J: "Code for the frequency of pain during the observation period in J2a. Code the highest intensity of pain that occurs during the observation period in J2b." (For more information on the manual update, see the next MDS Alert.)


Ready or not: Staffing and weight loss QMs are set to debut soon. Just as nursing home providers were getting used to the "enhanced" set of 14 quality measures that came on line in January, the Centers for Medicare & Medicaid Services announced it plans to add two new staffing and weight loss QMs later this year -- probably in the fall. The staffing measure is viewed as the most problematic of the two. Right now CMS is looking at using OSCAR data -- which is already reported on the Nursing Home Compare Web site - to compute the staffing measure. "Facilities report the staffing information during the annual survey when they complete a form HCFA 671 Long Term Care Facility Application for Medicare and Medicaid," says Carolyn Lehman, MSN, RN, NHA, a consultant with Howard, Wershbale & Co. in Cleveland, OH. "The form includes a chart to fill in all the staff hours worked in various staff categories for the most recent complete pay period," she says.

The problem is that facilities classify staff differently, Lehman notes. "For example, some MDS coordinators get pulled to the floor or also serve as unit managers, and one facility will count that as direct care and another won't," she says. "So there are a lot of inherent problems with the staffing QM which will make the information only marginally useful in comparing staffing at facilities," Lehman adds.

Providers have also asked CMS to report the staffing measure in the context of a facility's acuity level. Yet an approach to adequately adjust staffing threshold for differences in case-mix and acuity has yet to be worked out, notes Ruta Kadonoff, senior health policy advisor with the American Association of Homes & Services for the Aging. "Two facilities with identical staffing but very different populations may in fact be at opposite ends of the spectrum with regard to quality," Kadonoff says. 


Don't expect CMS to be so gracious if your SNF shows a pattern of overusing grace days for the MDS without a reason. Yes, CMS has provided "grace days" for setting the MDS assessment reference date, but should your facility use them routinely? CMS tackled this question at a recent SNF Open Door Forum, noting that the grace days are intended to accommodate various scenarios. Examples include times when facilities' staff cannot get all of the assessments done within the assessment window -- "for example if a patient has a bad cold and the MDS staff wanted the patient to stabilize before doing the assessment -- or if the SNF has a new patient and wants to correctly reflect that patient's needs," said an agency representative at the ODF.  Yet CMS does frown on a pattern of routine overuse of grace days. Good idea: Experts suggest documenting your rationale for using grace days for a particular MDS assessment.