MDS Alert

CMS suggests the RAI process can improve care for mentally ill residents.

To avoid a slate of F tags, nursing facilities need to take a new look at how they're meeting the OBRA-required Preadmission Screening and Resident Review (PASRR) requirements, and addressing residents' mental health care needs.

The survey challenge: PASRR is blazing on surveyors' radar screens, thanks to an HHS Office of Inspector General report that found compliance shortfalls with the program designed to prevent state facilities from "dumping" people with serious MI/MR in Medicaid-certified nursing homes that aren't equipped to meet their needs.

MDS to the rescue: Facilities can use the RAI process to help comply with the regulations, according to Cindy Hake, RN, MA, with the Centers for Medicare & Medicaid Services, who spoke during a recent CMS Webcast, "Mental Illness in Nursing Homes."

PASRR in a nutshell: Nursing home applicants with statutorily defined serious mental illness or retardation require a state-performed PASRR level II evaluation to determine the nursing home placement is appropriate -- and to identify any specialized services the person requires for his MI/MR. The state must provide or arrange for those services. The PASRR level II report may also identify mental health services that the nursing facility can provide (to read the specific PASRR requirements and exclusions, see the handouts for "Mental Illness in Nursing Homes" at http://cms.internetstreaming.com).

6 Steps to Success

These MDS-related processes can help you stay on top of PASRR requirements and residents' mental health needs.

1. Start with Section AB. If you know at admission that a resident has a history of mental illness or retardation/developmental disability, record that information in AB9 or AB10 in the background information section on the MDS, Hake advised.

Expect records: If you indicate at AB5d that the resident has been in a psychiatric/mental health facility, you'd expect to receive a considerable history and medical records about the related issues, says Reta Underwood, principal, Consultants for Long-Term Care in Buckner, KY.

2. Code a resident's mental illness diagnosis in Section I. If the person has an active diagnosis of mental illness, record that in Section I1, Hake advised. If there's no checkbox for the mental condition, enter the ICD-9-CM code in I3.

3. Identify any residents with a previously missed or new serious mental illness. The nursing home staff is responsible for identifying and notifying the state mental health authority about residents who develop a serious mental illness -- or ones who may have been admitted without anyone realizing they had serious MI. In that regard, the MDS may reveal over time that a resident has mood and behavioral issues accruing in Section E.

Section F (psychosocial well-being) is also important for assessing mental health issues, Underwood adds.

Some Resident Assessment Protocols also identify residents who may require further evaluation and care planning for mental health issues. The list of RAPs includes delirium, psychosocial well-being, mood state, behavioral symptoms, psychotropic drug use and physical restraints, Hake said.

Check who's triggering on the psych-related QIs/QMs: Make a list of residents who flag on antipsychotic use without a psychotic or related conditions or on depression symptoms without an antidepressant. That will give you a starting point for identifying candidates for a mood and behavioral intervention program, Underwood suggests.

4. Incorporate MDS, RAP and PASRR level II information in developing a resident-specific plan. That includes any mental health services which the facility should provide to meet the resident's needs, regardless of whether they are specified in the PASRR level II report, according to the Webcast. The services include systematic plans to change behaviors, drug therapy and monitoring, structured environment, formal behavioral modification and individual, group and family therapy, said CMS' Webcast presenter Nadine Renbarger, MA, a technical advisor for the agency.

Tip: The plan of care should address the resident's mental health symptoms and behaviors, Renbarger stressed. The care plan goals should be specific and not simply to reduce signs and symptoms or monitor for medication side effects.

5. Code your psychological and behavioral interventions on the MDS. Section P is where you find the interventions related to Sections E and F, Underwood notes. For example, use P1be to capture psychological therapy by any licensed mental health professional, including a psychiatrist, psychologist, psychiatric nurse or psychiatric social worker.

P2a-e includes numerous intervention programs for mood, behavior and cognitive loss (see page 9 for the complete list).

Christine Twombly, RN, RAC-C, sees a lot of facilities that fail to code a resident's mental health services in Section P.

For example, "the facility may actually be contracting for psychological services to provide counseling," she says. If that's the case, the facility can code those minutes in P1b, advises Twombly, chief clinical consultant for Reingruber & Co. in St. Petersburg, FL.

Coding tip: Make sure to code antipsychotic medications and antidepressants in Section O4.

6. Be on the lookout for significant change in status assessments for residents admitted with a PASRR II evaluation. If such residents require an SCSA for a change in physical or mental functioning, the nursing facility must contact the state mental health authority and tell them, CMS Webcast presenters said.

The state will then decide whether the significant change might impact PASRR II determinations and thus require a resident review.

Not only that: The state is supposed to evaluate any resident who nursing home staff suspects has a serious mental illness not diagnosed previously -- or a new diagnosis of serious mental illness, such as schizophrenia, according to the CMS Webcast.