MDS Alert

Consider using these 2 CMS survey forms to manually track quality issues.

Think of it as an eclipse that will make your quality improvement efforts more difficult: Once the MDS 3.0 goes live, nursing facilities and surveyors will move into a temporary "blackout" phase where they won't have access to the quality indicators/measures reports. And now is the time for your team to start thinking through options for how to make do without those automated QI/QM reports flagging quality-of-care concerns and residents in need of more in-depth review.

In a nutshell: The Centers for Medicare & Medicaid Services will take down the QI/QM reports for a "number of months" after MDS 3.0 implementation because there won't be enough residents in a particular nursing facility with MDS 3.0 assessments to populate the reports for some time, confirmed the agency's Karen Schoeneman, in a CMS Webinar on the MDS 3.0.

The bottom line: Facilities will have to find a way to track their clinical issues during that time, says Sue  LaBelle, RN, MSN, a healthcare specialistwith PointRight Inc. in Lexington, Mass. "Internally, facilities should be able to track prevalence-based measures, such as falls, pressure ulcers, infections, etc.," LaBelle says.

You'll have more tools at your disposal than incident reports and negative outcome tracking. Facilities can also use the CMS 802 (roster/sample matrix) and CMS 672 (resident census and conditions) forms to stay on top of their quality issues, suggests Marty Pachciarz, RN, RAC-CT, managing clinical director with the Polaris Group in Tampa, Fla.

First step: Print out and complete the forms sometime before September, Pachciarz advises. "Start with the baseline information on those forms and from that point on keep both forms current."

Update the forms as you do the MDS, Pachciarz advises. "You could mark on the roster (CMS 802) that a resident had a decline in ADLs or a decline in cognition based on what the MDS nurse just coded compared to the prior MDS" (see the form on page 16). The MDS nurse may need training on the roster definitions and the QI/QM qualifying criteria, Pachciarz notes. Using the form, you see who is "interviewable and not, and people on hospice and dialysis or those with MI/MR."

Fill in the gaps: Incorporate and update the information in the weekly risk management meeting as you review residents and update their conditions in between MDS assessments.

"The team could even do this at the daily stand-up meetings," Pachciarz suggests.

Perk: Using a current roster (CMS 802), the QA team could focus on a single resident with multiple problem areas whom the surveyors would likely target for the survey,  Pachciarz says. You can also see care area trends across residents on the roster, she adds.

As for the CMS 672: Using that form, you can, for example, compare over time a number of issues, such as the number of pressure ulcers and people admitted with pressure ulcers, and people with contractures and how many had those at admission, she points outs. "You could calculate the percent using your census and make some conclusions based on that information," Pachciarz adds.

Software heads up: CMS plans to help vendors get on the same page with their software for completing the CMS 802 and CMS 672 forms. In a recent MDS 3.0 software vendor call, CMS officials stated that the agency plans to address the CMS 672 and 802 forms with crosswalks "so that vendors would have a consistent update from MDS 3.0 items" to these forms, says Peter Arbuthnot, regulatory analyst for American HealthTech in Jackson, Miss. "CMS has not given a set date on when this information will be made available," Arbuthnot adds.