Residential Care Facility Forum Call

1. Residential Care FacilityForum Call Case Mix Unit / Office of MaineCare Services September 6, 2018

2. Residential Care Facility Forum Call 9/6/18 Welcome to the 3rd Quarter Residential Care Forum Call Department of Health and Human Services

3. Residential Care Facility Forum Call 9/6/18 Agenda Welcome HIPAA reminders Review of MDS-RCA Questions and Answers Snippet Training: B3 Announcements Questions Department of Health and Human Services

4. Residential Care Facility Forum Call 9/6/18 HIPAA Reminder: When sending email, please do not include any identifying information. This table developed by the federal Department of Health and Human Services gives definitions of 18 examples of identifying information. Department of Health and Human Services

5. Residential Care Facility Forum Call 9/6/18 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. Department of Health and Human Services

6. Residential Care Facility Forum Call 9/6/18 For more information: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/De-identification/guidance.html Department of Health and Human Services

7. Residential Care Facility Forum Call 9/6/18 Questions, Questions, Questions … and Answers Department of Health and Human Services

8. Residential Care Facility Forum Call 9/6/18 Section P If a resident goes to an appointment and they return with paperwork that says “Return to clinic in 3 months,” would I count this as an order change because the doctor is ordering that they go back in again? Department of Health and Human Services

9. Residential Care Facility Forum Call 9/6/18 MDS-RCA Manual, page 116: Physician Orders - Includes written, telephone, fax or consultation orders for new or altered treatment. Does NOT include standard admission orders, return admission orders, renewal orders, or clarifying orders without changes. Orders written on the day of admission as a result of an unexpected change/deterioration in condition or injury are considered as new or altered treatment orders and should be counted as a day with order changes. A recommendation to return for another visit does not change the resident’s orders; it is not a new or altered treatment. Department of Health and Human Services

10. Residential Care Facility Forum Call 9/6/18 Section E Regarding Section E1a-r, if a resident’s S2b date is due on a certain date, but the MDS-RCA cannot be done because the resident is in the hospital. I understand that we will complete the MDS-RCA with 14 days of the resident’s return, but we will only have 14 days to evaluate the resident’s mood and behavior.  Does this mean that we cannot code section E1a-r? Department of Health and Human Services

11. Residential Care Facility Forum Call 9/6/18 E1.          Indicators of Depression, Anxiety, Sad Mood Intent:To record the frequency of indicators observed and reported in the last 28 days (or since admission if less than 28 days), irrespective of the assumed cause of the sign or symptom (behavior).  (6/1/17) MDS-RCA manual, page 46: Coding: (3/1/18) 0.  Indicator exhibited less than one day each week in last 28 days 1.  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. Department of Health and Human Services

12. Residential Care Facility Forum Call 9/6/18 E1 Calculator Department of Health and Human Services

13. Residential Care Facility Forum Call 9/6/18 Section A We currently have a resident who has outright refused to provide us with their SSN even after attempts to reassure them that it will be kept confidential. In this case what would you advise? The social security field is a required field on the MDS-RCA.  The assessment will be rejected if the item is left blank or filled in with zeros. For this particular resident, you may use 333-33-3333 as the SSN. If this scenario comes up again, you will need to contact Catherine Gunn to be assigned a number that is not already in use. We do not want to risk having duplicate numbers in the database.  Department of Health and Human Services

14. Residential Care Facility Forum Call 9/6/18 Discharge For private pay residents being discharged, what date should be used for MDS Discharge date? a. The date the resident leaves the building acute for the hospital prior to rehab/nursing home admit? (even if at the time of going out of the facility we assume return?) or b. The date the resident gives notice to our facility that do not plan to return? or c. The date the rent has been paid through? (for example, if a 30 day vacate notice has been given by family) Department of Health and Human Services

15. Residential Care Facility Forum Call 9/6/18 The discharge date on the MDS-RCA and for MaineCare billing purposes is the date the facility becomes aware the resident will not be returning (Return not anticipated). Department of Health and Human Services

16. Residential Care Facility Forum Call 9/6/18 Section K For Level IV PNMI Residential Care Facilities, is it necessary to have a Diet Order for Residents? (If Therapeutic diets are not offered, and all other regulations are being followed.) This is more of a Licensing question than an MDS question. A facility needs to know if the resident has special dietary needs, restrictions, or allergies. Physician order is required for a therapeutic diet. Therapeutic diet is not always about elimination of certain foods; a therapeutic diet is used to treat a condition, such as allergies, etc.  Department of Health and Human Services

17. Residential Care Facility Forum Call 9/6/18  From 10-144 Chapter 113: Regulations Governing the Licensing and Functioning of Assisted Housing Programs, Level IV Private Non-Medical Institutions (PNMI): 11.1.4    Written and dated orders signed by a duly authorized licensed practitioner for all treatments, medications and special diets.  14.2        Adequacy of diets.  The facility must offer each resident a nourishing, well-balanced diet that meets the daily nutritional and special dietary needs of each resident and that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. 14.6Therapeutic diets.  Therapeutic diets are considered treatments and shall be ordered in writing by the duly authorized licensed practitioner.  Menus for medically prescribed therapeutic diets shall be planned in writing and approved by a qualified consultant dietitian.  14.7Diet manual.  Each facility shall have a current (not more than five [5] years old) therapeutic diet manual that is recommended or approved by a qualified consultant dietitian.

18. Residential Care Facility Forum Call 9/6/18 Section A Can a Medicare replacement/Advantage-HMO Number be used in the Medicare field on the MDS? Medicare numbers is not a required field, as not all residents have Medicare. The limitations of the field size would allow only traditional Medicare numbers, not other policy numbers with a different number of characters. The new Medicare numbers have 11 characters. This could also be a software issue with the type of characters, i.e. letters vs. numbers. Department of Health and Human Services

19. Residential Care Facility Forum Call 9/6/18 Section O The respiratory therapist is working on the orders. The question has come up whether we need to have the order and/or the TAR say “Incentive spirometer x15 mins.” “Acapella x15 mins.” The thought is that if the respiratory therapist isn’t seeing the resident that day, the nurse would have to stay with the resident for 15 mins. when they really don’t have the time to do that with all the residents that have incentive spirometer, acapella,etc. Would it work if the order stated respiratory therapy x 15 mins. to include acapella or to include incentive spirometer? Would the respiratory therapist’s documentation showing the incentive spirometer, acapella, etc. x 15 mins. be enough? It was not clear in the question if this scenario referred to NF or RCF. Department of Health and Human Services

20. Residential Care Facility Forum Call 9/6/18 The order would not have to specify the exact number of minutes, but the staff person would want to document the exact number of minutes the treatment was done. The reason being… if the order is written for the treatment to be completed 15 minutes, and the resident completes only 10 minutes, do you circle it as not completed? If you are coding for respiratory therapy on the MDS, only the time spent with the resident would count toward respiratory therapy. For example, lung sounds before, followed by a few minutes of teaching/observation to ensure proper technique, then lung sounds and assessment after the technique. If this takes eight minutes, then document staff time of eight minutes and resident time of 15 minutes if that is time used. Coding on the MDS would be the number of days the resident received 15 minutes or more if “respiratory therapy,” meaning the actual time licensed staff spent with the resident not the number of minutes the resident spent completing the technique (nebulizer, incentive spirometer, etc.). Department of Health and Human Services

21. Residential Care Facility Forum Call 9/6/18 Section A Is significant change required for a resident starting or discontinuing hospice care? A significant change would not be required unless… There were two or more changes in the resident’s clinical status and the facility needed to revise the care plan to ensure resident needs are being addressed and care is coordinated with the hospice agency. Department of Health and Human Services

22. Residential Care Facility Forum Call 9/6/18 Section A I’m confused as to when the S2b date should be. I understand that once a event is documented on a certain date and there is a potential for a significant change in clinical status, the S2b date should be within 14 days. When do we determine if the event is self-limiting or not? According to the manual, the definition for self-limiting means the condition will normally resolve itself without further intervention or by staff implementing standard interventions within 14 days. Which 14th day comes first? In my mind, before I determine if there is a significant change, I have to establish if the change is self-limiting or not within 14 days. Please clarify.  Department of Health and Human Services

23. Residential Care Facility Forum Call 9/6/18 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. MDS-RCA Manual, page 31 Department of Health and Human Services

24. Residential Care Facility Forum Call 9/6/18 A Significant Change assessment is warranted if there is a consistent pattern of change with two or more areas of decline or improvement ofthe 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. MDS-RCA Manual, page 32 Department of Health and Human Services

25. Residential Care Facility Forum Call 9/6/18 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 MDS-RCA Manual, page 32 (Section A) The S2b date must be signed as being complete within seven days of the Assessment date (item A5). When calculating the due date for subsequent assessments, the S2b date is day one. MDS-RCA Manual, page 118 (Section S) Department of Health and Human Services

26. Residential Care Facility Forum Call 9/6/18 Thank you for bringing this to our attention. • The event or situation is documented in the clinical record. • The facility determines that the situation has lead to changes that are not going to be resolved with standard staff interventions within 14 days. • The facility sets an assessment date (item A5) which will become the end of all look back periods for an assessment that must be completed (signed at S2b) no later than 14 days after the identification of the event or situation AND, the S2b date must be within seven days of the A5 date. Department of Health and Human Services

27. Residential Care Facility Forum Call 9/6/18 Section A Regarding significant change, can you give me examples of identification of an event(s) or situation that may lead to the completion of a significant change assessment. I have several examples; but first, I would like to hear from other facilities. What are some situations that have lead you to complete a significant change assessment? Department of Health and Human Services

28. Residential Care Facility Forum Call 9/6/18 Questions?? Comments?? Department of Health and Human Services

29. Residential Care Facility Forum Call 9/6/18 Snippet Training Clarification of Changes to B3 Cognitive Skills for Daily Department of Health and Human Services

30. Residential Care Facility Forum Call 9/6/18 Snippet Training Clarification of Changes to B3 Cognitive Skills for Daily Decision-Making Department of Health and Human Services

31. Residential Care Facility Forum Call 9/6/18 Intent: To record the resident's actual performance in making everyday decisions about the tasks or activities of daily living. Process: 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. 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. Department of Health and Human Services

32. Residential Care Facility Forum Call 9/6/18 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. Department of Health and Human Services

33. Residential Care Facility Forum Call 9/6/18 0. Independent • Modified Independence • Moderately Impaired –The resident's decisions were poor; the resident required reminders, cues, and supervision in planning, organizing, and conducting daily routines. • 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. Department of Health and Human Services

34. Residential Care Facility Forum Call 9/6/18 Questions?? Comments?? Department of Health and Human Services

35. Residential Care Facility Forum Call 9/6/18 The website to obtain copies of the training calendar, training manual, the training Powerpoint and handouts, etc. is: http://www.maine.gov/dhhs/oms/provider/case_mix_manuals.html Department of Health and Human Services

36. Residential Care Facility Forum Call 6/7/18 Residential Care Facility Forum Call 9/6/18 Upcoming MDS-RCA training: Sept 19, 2018 – Biddeford Oct 19, 2018 - Augusta 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: Dec 6, 2018 Department of Health and Human Services

37. Residential Care Facility Forum Call 9/6/18 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

38. Residential Care Facility Forum Call 9/6/18 Contact Information: • MDS Help Desk: 624-4019, or 1-844-288-1612 (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

39. Questions? Thanks for spending time with the case mix team See you in December! Sue Pinette 207-287-3933 Department of Health and Human Services