Residential Care Facility Forum Call

1. Residential Care FacilityForum Call Case Mix Unit / Office of MaineCare Services June 7, 2018 Department of Health and Human Services

2. Residential Care Facility Forum Call (6/7/18) Agenda • Welcome • HIPAA Reminders • Review of MDS-RCA Questions and Answers • Snippet Training • Announcements • Questions Department of Health and Human Services

3. Residential Care Facility Forum Call (6/7/18) HIPAA Reminder: When sending email, please do not include any identifying information. This table developed by the Federal Department of Health and Human Services provides 18 examples of identifying information. Department of Health and Human Services

4. Residential Care Facility Forum Call (6/7/18) If you need to send a portion of an MDS record: • Fax is preferred over email • If you must email, paste the document into a Word document and apply a password. Do NOT send the password in the same email as the attached MDS document, OR • Black out all identifying information, such as name, social security number, DOB, etc. It is acceptable to refer to a resident as #1, #2, according to a list of residents left during a case mix review. • If you mail information, please label as confidential and identify the person to whom it is being sent. FMI: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/Deidentification/guidance.html Department of Health and Human Services

5. Residential Care Facility Forum Call (6/7/18) Department of Health and Human Services

6. Residential Care Facility Forum Call (6/7/18) Section A - I know that the admission is required by Day 30. However, I am wondering whether one is required if the resident leaves prior to the 30th day. • You are not required to complete an assessment if the resident was discharged before day 30. You will complete the discharge tracking form, with item 8 (reason for assessment) coded as “7,” (discharged prior to completing initial assessment.)  • The facility can bill for days the resident was in the facility, based on the facility’s case mix average as identified in your rate letter that goes into effect 1/1 and 7/1. This would be true for residents with a short stay and discharge to hospital or skilled nursing facility without expectation of return, or for residents admitted for short-term (less than 30 days) respite care.  • The facility will have to have submitted a movement card to OADS identifying the date of admission so that there is a classification code in the billing system in order to submit a claim for a resident.   

7. Residential Care Facility Forum Call (6/7/18) Department of Health and Human Services

8. Residential Care Facility Forum Call (6/7/18) Section E - I am trying to find the source in the RCA reference to a change in requiring the mood be documented once in every seven day look back. I thought the RCA manual dated 6/2/2017 referenced having to be an average in the four week look back. Could you tell me where in the RCA I can find the changes requiring the documentation to show needing weekly back? MDS-RCA Manual attached. See page 48: Process: Review daily staff documentation, consult with or interview staff across all shifts for the timeframe of the observation. Daily staff documentation for all shifts is the preferred method to support the coding of these indicators. When daily documentation is not utilized, the results of the consultations and/or interviews must be documented in the resident’s record to support the entire timeframe. Coding: For each indicator, apply one of the following codes based on interactions with and observations of the resident in the last 28 days. Remember, code regardless of what you believe the cause to be. (3/1/18) Department of Health and Human Services

9. Residential Care Facility Forum Call (6/7/18)  Coding: (3/1/18) 0. Indicator exhibited less than one day each week in last 28 days • Indicator exhibited one to five days per week during the past 28 days. Behavior must have occurred at least one day every week. 2. Indicator exhibited daily or almost daily (6 to 7 days each week) during the past 28 days or the average of the four weeks is 6.0 or greater. NOTE: Average is defined as the total of the values for each week in the look-back period divided by number of weeks in the look-back period. Department of Health and Human Services

10. Residential Care Facility Forum Call (6/7/18) Updated E1 Calculator (28 day look-back period) Department of Health and Human Services

11. Residential Care Facility Forum Call (6/7/18) Facility sold to a new owner, not accepting assignment, what do I do next? Since your facility is not assuming assignment, Case Mix will treat your facility as a brand new facility. Discharge assessments will need to be submitted from the "old" facility for all residents, and you will need to submit admission assessments for all residents under the new NPI number.  After the facility information has been entered into the State MDS database, Catherine will let you know what Facility Provider number will be used for Section AA6b and Section A3b on the MDS. This number will also need to used in the header for your MDS-RCA software submissions.  If you have questions on your software, please contact your vendor. Department of Health and Human Services

12. Residential Care Facility Forum Call (6/7/18) Section M - Per the RCA manual, ulcers are coded for any cause. If the identified ulcer is deemed a deep tissue injury per the NPUAP, at what stage should this be coded on the MDS-RCA? Per the MDS-RCA Manual, page 98 :  M2.        Ulcers  Intent:  To record the presence of ulcers of any stage, on any part of the body, in the last 7 days.  Definition:Ulcer – Any lesion caused by pressure or decreased blood flow resulting in damage to underlying tissues.  Stage 1.   A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. Stage 2.  A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater. Stage 3.  A full thickness of skin is lost, exposing the subcutaneous tissues - presents as a deep crater with or without undermining adjacent tissue. Stage 4.  A full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone.  Department of Health and Human Services

13. Residential Care Facility Forum Call (6/7/18) • Note: If eschar and necrotic tissue are covering and preventing adequate staging of a pressure ulcer, the assessor will document and code the pressure ulcer as a Stage IV until the eschar has been debrided (surgically or mechanically) to allow staging. These instructions must be followed for MDS-RCA coding purposes until they are revised. Although the AHCPR and NPUAP system for staging pressure ulcers indicates that the presence of eschar precludes accurate staging of the ulcer, the facility must use these directions in order to code the MDS-RCA, but not necessarily to render treatment. Documentation must accurately reflect findings from assessments that were conducted.  • For the MDS-RCA assessment, staging of ulcers should be coded in terms of what is seen during the look-back period. For example, a healing stage 3 that has the appearance of a stage 2 pressure ulcer must be coded as a “2” for purposes of the MDS-RCA assessment. Facilities certainly may adopt the National Pressure Ulcer Advisory Panel (NPUAP) standards in their clinical practice. However, the NPUAP standards cannot be used for coding on the MDS-RCA.  Department of Health and Human Services

14. Residential Care Facility Forum Call (6/7/18) Reminder: The MDS is a MINIMUM Data Set. It is not a comprehensive assessment. A facility may document using NPUAP guidelines and there is a possibility that not all injuries will be captured on the MDS-RCA. Injuries and treatments must be captured on the service plan to ensure the resident is receiving all necessary care. Department of Health and Human Services

15. Residential Care Facility Forum Call (6/7/18) I was thinking about the question included on slide 34 of today's presentation. In looking at the toileting use definition and page 61 of the training manual, I was wondering why limited assistance would not be an appropriate response. In reading the definition of limited assistance, it indicates physical assistance orother non-weight-bearing assistance. Could you please clarify why limited assistance would not be a valid code for the question posed? Section G (Slide 34 from 3/1/18 call) - We have a resident who is not capable of emptying their own catheter bag and staff is preforming this task, how would the CNA’s code this? MDS-RCA Manual, page 57:  Toilet Use – How the resident uses the toilet room, commode, bedpan, or urinal, transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, and adjusts clothes. Department of Health and Human Services

16. Residential Care Facility Forum Call (6/7/18) Limited Assistance – Resident highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight-bearing assistance on three or more occasions – OR – limited assistance (three or more times) plus weight-bearing support provided only one or two times during last seven days. (MDS-RCA Manual, page 62) The act of emptying the foley bag does not involve physical assistance and the resident is not highly involved with the activity; therefore, it cannot not be coded at all. Take all components of toileting into account when coding G1f. Toilet use. Department of Health and Human Services

17. Residential Care Facility Forum Call (6/7/18) Raises more questions that it answers! Does the resident manage daily catheter care? Don’t forget about other components of toileting… on/off toilet, cleansing self, bowels and bladder, adjusting clothing, etc. Department of Health and Human Services

18. Residential Care Facility Forum Call (6/7/18) Section G – Please clarify ability to code 1/1 for eating under the definition of supervision is specifically states “encouragement” OR cueing. If we have the dining room staffed and they are specifically going to the resident and encouraging them to eat or increase their fluid intake. If it is in their service plan as well that we will provide cueing and encouragement. Are we able to code as a 1/1? MDS-RCA Training Manual, page 62 1. Supervision – Oversight, encouragement, or cueing provided three or more times during last seven days – OR – supervision (three or more times) plus physical assistance provided only one or two times during last seven days. Supervision of eating involves direct supervision of the resident. Oversight of all residents in the dining room cannot be coded as supervision for the individual resident. The service plan must describe the need for supervision, i.e. related to risk of choking, the resident needs direct cueing in order to eat, etc. Department of Health and Human Services

19. Residential Care Facility Forum Call (6/7/18) Section P - When a resident goes to a “walk-in clinic” should it be documented as an ER visit or MD visit? A walk-in clinic visit can be captured at P9 as MD visit, not as an ER visit, as the visit is being used to replace an MD office visit unless it is a medical emergency. Visits for a medical emergency such as chest pains, bleeding, serious injury, or other life-threatening conditions would require an ER evaluation and treatment. MDS-RCA Manual, page 115: Physical exam – May be a partial or full exam. This does NOT include exams conducted in an emergency room. If the resident was examined by a physician during an unscheduled emergency room visit, record the number of times this happened in Item 06, “Emergency Room” (Visits). Department of Health and Human Services

20. Residential Care Facility Forum Call (6/7/18) Section A - With Medicare number changes coming, are we going to need to do MDS corrections? Is the number change going to cause a rejection of assessments upon submission? From CMS.gov: How many characters will the MBI have? The MBI has 11 characters, like the HICN, which can have up to 11. What kinds of characters will be used in the MBI? MBIs are numbers and uppercase letters. We’ll use numbers 0-9 and all letters from A to Z, except for S, L, O, I, B, and Z. This will help make the characters easier to read. How will the MBI look on the new card? The MBI will contain letters and numbers. Here’s an example: 1EG4-TE5-MK73 The MBI’s 2nd, 5th, 8th, and 9th characters will always be a letter Characters 1, 4, 7, 10, and 11 will always be a number The 3rd and 6th characters will be a letter or a number

21. Residential Care Facility Forum Call (6/7/18) You will not have to enter the Medicare number on the MDS-RCA as the current form will not accommodate a 11-digit number. You may get a warning, but the assessment will not be rejected.

22. Residential Care Facility Forum Call (6/7/18) Department of Health and Human Services

23. Residential Care Facility Forum Call (6/7/18) Snippet Training - MDS-RCA Training Manual Updates effective 6/1/18 MDS-RCA Manual, Effective 6/1/18 Department of Health and Human Services

24. Residential Care Facility Forum Call (6/7/18) Change Tables for MDS-RCA Manual, Effective 6/1/18 Department of Health and Human Services

25. Residential Care Facility Forum Call (6/7/18) Significant Change (page 31) Significant change in status assessment – A comprehensive reassessment prompted by a “major change” that is not self-limited, that impacts two or more areas of the resident's clinical status, and requires revision of the service plan. The assessment must be completed by the end of the 14th calendar day following the determination that a significant change has occurred. “Self-limiting” means the condition will normally resolve itself without further intervention or by staff implementing standard interventions within 14 days. Department of Health and Human Services

26. Residential Care Facility Forum Call (6/7/18) Significant Change (page 32) A Significant Change assessment is warranted if there is a consistent pattern of change with two or more areas of declineor improvement of the resident’s clinical status. Documentation of the identification of an event or situation that may lead to completion of a significant change assessment must be in the resident’s clinical record. This note will serve as the beginning of the observation period to determine if there are changes in the resident’s condition that meet the definition of “significant change” (i.e. a major change that is not self-limiting, impacts two or more areas of the resident’s clinical status, and requires revision of the service plan) to ensure the change in the resident’s needs is being addressed. A single note in the clinical record on or around the assessment date (item A5) indicating the resident had a significant change without documentation of the qualifying characteristics does not meet the requirements for a significant change. The MDS-RCA assessment must be completed at item S2b with revision of the service plan no later than 14 days after the identification of the event or situation that lead to completion of the significant change assessment. Department of Health and Human Services

27. Residential Care Facility Forum Call (6/7/18) Cognitive Skill for Daily Decision-Making (page 39-40) Review the clinical record. Consult family and caregiver staff. Observe the resident. The inquiry should focus on whether the resident is actively making these decisions, and not whether staff believes the resident might be capable of doing so. A resident who makes a poor decision is still making a decision. Remember the intent of this item is to record the resident’s actual performance. When a staff member has taken decision-making responsibility away from the resident regarding tasks of everyday living, or the resident is unable to participate in decision-making, the resident should be considered to have impaired performance in decision-making. This item is especially important for further assessment and care planning in that can alert staff to a mismatch between a resident's abilities and his or her current level of performance, or that staff may be inadvertently fostering the resident's dependence. When coding, identify the most representative level of function, not necessarily the highest. Staff must use clinical judgment to decide if a single observation provides sufficient information on the resident’s typical level of function. There must be documentation to support all coding on the MDS. The look-back period for this item is seven days.

28. Residential Care Facility Forum Call (6/7/18) Cognitive Skill for Daily Decision-Making (page 39-40) Theclinical record must include documentation of the resident’s actual performance in making everyday decisions about tasks or activities of daily living within the look-back period. The documentation must include specific examples of resident behaviors and ability to make decisions to support the coding selected. Coding: Check the numbered box that is the most representative level of function, not necessarily the highest. Staff must use clinical judgment to decide if a single observation provides sufficient information on the resident’s typical level of function. 0. Independent (no change) 1. Modified Independence – The resident organized daily routine and made safe decisions in familiar situations but experienced some difficulty in decision making when faced with new tasks or situations. If there have been no new tasks or situations within the look back, this choice cannot be coded. 2. Moderately Impaired – The resident's decisions were poor; the resident required reminders, cues, and supervision in planning, organizing, and conducting daily routines. 3. Severely Impaired – The resident's decision-making was severely impaired; the resident never made independent decisions. If the resident does not respond to reminders, cues, or supervision, the resident is dependent on others for everyday decision-making.

29. Residential Care Facility Forum Call (6/7/18) Questions? Comments? Department of Health and Human Services

30. Residential Care Facility Forum Call (6/7/18) Upcoming MDS-RCA training: June 15, 2018 – Augusta July – TBA (where is it needed?) Sept 19, 2018 – Biddeford Call the help desk or your case mix nurse if you want information on ADL documentation training. Call or email to register: MDS3.0.DHHS@maine.gov Next call: Sept 6, 2018 You can access the training calendar, training manual, training PowerPoint, and handouts, etc. at: http://www.maine.gov/dhhs/oms/provider/case_mix_manuals.html Department of Health and Human Services

31. Residential Care Facility Forum Call (6/7/18) The first line of information for the MDS Resident Care Assessment Tool is the training manual. If there is a specific case that you are unsure of coding, call your case mix nurse or the MDS help desk for more guidance. Department of Health and Human Services

32. Residential Care Facility Forum Call (6/7/18) Contact Information: • MDS Help Desk: 624-4019, or1-844-288-1612 (toll-free), MDS3.0.DHHS@maine.gov • Lois Bourque RN: 592-5909, Lois.Bourque@maine.gov • Darlene Scott-Rairdon RN: 215-4797, Darlene.Scott@maine.gov • Maxima Corriveau RN: 215-3582, Maxima.Corriveau@maine.gov • Sue Pinette RN: 287-3933 or 215-4504 (cell), Suzanne.Pinette@maine.gov Department of Health and Human Services

33. Questions? Thanks for spending time with the case mix team! See you in September! Department of Health and Human Services