MDS 3.0 Sections C, D, E, F, Q

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1 MDS 3.0 Sections C, D, E, F, Q & Quality Measures Carol Hill RN, BSN, RAC-MT, C-NE, CDP Objectives Identify two methods for conducting resident interviews Describe how to conduct an assessment of a resident s cognitive patterns, mood and customary routine and activities Code sections C, D, E, F and Q of the MDS 3.0 correctly and accurately INTERVIEWS 1

2 MDS 3.0 Interviews Direct interview is the primary source of information for sections on mood, preferences and pain. MDS 3.0 Interviews Interview approaches Introduce yourself Be sure the resident can hear what you are saying If the resident does not appear to be fluent in English or continues to have difficulty understanding ask whether the resident would like an interpreter (language or signing) Find a quiet, private area where you are not likely to be interrupted or overheard MDS 3.0 Interviews Interview approaches Sit where the resident can see you clearly and you can see his or her expressions Establish rapport and respect Explain the purpose of the questions to the resident Say and show the item responses Ask the questions as they appear on the questionnaire 2

3 MDS 3.0 Interviews Interview approaches Break the question apart if necessary Unfolding: refers to the use of a general question about the symptom followed by a sequence of more specific questions if the symptom is reported as present. Disentangling: refers to separating items with several parts into manageable pieces. Clarify using echoing Echoing: restating part of the resident s response. MDS 3.0 Interviews Guide the Conversation Some residents are eager to talk and may stray from the topic. Acknowledge the response and guide the conversation back to the topic. That s interesting, now I need to know.. Let s go back to I understand, can you tell me about.. MDS 3.0 Interviews Ask for Clarification Validate your understanding of what the resident is saying. I think I hear you saying that. Let s see if I understand you correctly. Let s see if I understand you correctly. You said.. Is that right? 3

4 MDS 3.0 Interviews Probing Explore noncommittal responses such as not really. Gently encourage reluctant residents to report any symptoms. Probe by asking neutral or nondirective questions. What do you mean? Tell me what you have in mind. Tell me more about that. Please be more specific. Give me an example. MDS 3.0 Interviews Repeat the response options Move on to another question Break up the interview Do not try to talk a resident out of an answer Record the resident s response Sympathetically respond to their feelings Encourage to articulate their desires Interviews for Unplanned Discharges Unplanned Discharge Acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acutecare admission is required based on emergency department evaluation; or Resident unexpectedly leaving the facility against medical advice; or Resident unexpectedly deciding to go home or to another setting (e.g. due to the resident deciding to complete treatment in an alternate setting). 4

5 Discharges Planned Versus Unplanned The interview items are not active on a standalone unplanned discharge assessment. Interviews for Unplanned Discharges Combined with Another Assessment For the BIMS, PHQ-9, and Pain interviews, if the resident is discharged unexpectedly and the resident interview has not yet been completed the staff assessment should be completed if appropriate clinical record information is available. In this case the gateway questions, C0100, D0100, and/or J0200 should be coded No(0) and the staff assessment should be completed. Unscheduled Assessment Interviews When coding a standalone unscheduled PPS assessment (COT, EOT, SOT), the interview items may be coded using the responses provided by the resident on a previous assessment. If the interview i responses from the scheduled assessment were obtained no more than 14 days prior to the date of the unscheduled assessment on which those responses will be used. 5

6 COT Interviews When completing a COT OMRA you may complete the interview items one or two days after the ARD of the COT OMRA. This should not be your standard practice. When staff identify that the resident s primary method of communication is in written format, the BIMS can be administered in writing. The administration of the BIMS in writing should be limited to this circumstance. C0100. Should Brief Interview for Mental Status be Conducted? 0. No (resident is rarely/never understood) 1. Yes C0200. Repetition of Three Words I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue and bed. Now tell me the three words. 6

7 Category Cue Phrase that puts a word in context to help with learning and to serve as a hint that helps prompt the resident. Cues for C0200 are: For sock: something to wear For blue: a color For bed: a piece of furniture If resident recalls two or fewer words on first attempt: Make a second attempt. Repeat the words using category cues to prompt memory. If resident does not recall all the words on second attempt: Make a third attempt. Repeat the words and use cues. If resident does not repeat all three words after three attempts: Reassess the resident s ability to hear. If the resident can hear, move on to the next question. If he or she is unable to hear, attempt to maximize hearing before proceeding. 7

8 Words may be recalled in any order. Words may be recalled in any context. Repeating words in a sentence counts as repeating words. Score only the number correct on the first attempt only. Code refusals as incorrect Nonsensical responses should be coded as zero C0300 Temporal Orientation Ask each of the three questions separately C0300A Please tell me what year it is right now C0300B What month are we in right now? C0300C What day of the week is today? Allow up to 30 seconds for a response. Do not provide clues. If residents specifically ask for clues, tell them you need to know if they can answer without any help from me. C0300A Please tell me what year it is right now. 0. Missed by > 5 years or no answer 1. Missed by 2-5 years 2. Missed by 1 year 3. Correct 8

9 C0300B What month are we in right now? 0. Missed by > 1 month or no answer 1. Missed by 6 days to 1 month 2. Accurate within 5 days C300C What day of the week is today? 0. Incorrect or no answer 1. Correct C0400 Recall Ask the resident the following: Let s go back to an earlier question. What were those three words that I asked you to repeat? Allow up to five seconds for spontaneous recall. For any word that is not correctly recalled after 5 seconds, provide a category cue. Use category cues only after resident is unable to recall one or more of the three words. Allow up to five seconds after category cueing for each word to be recalled. 9

10 C0400 Code 0. No Cannot recall the word even after cueing. Responds with a nonsensical answer. Chooses not to answer. Code 1. Yes after cueing Requires a cue to remember the word. Code 2. Yes, no cue required Correctly remembers the word spontaneously without cueing. C0500 Summary Score Add up the values for C0200 through C0400 Total score reflects cognitive status Cognitively Intact Moderate Impairment Moderate Impairment Severe Impairment C0500 Summary Score Code the total score as a two-digit number. Code 99 if The resident chooses not to participate in the BIMS If four or more items were coded 0 because the resident chose not to answer or gave a nonsensical response or If any of the BIMS items is coded with a dash A zero score does not mean the interview was incomplete. 10

11 C0600 Should the Staff Assessment be Conducted? Review whether C0500 Summary Score is coded 99 Code 0, no if the BIMS was completed and scored between 00 and 15. Code 1, if C0500 is coded 99 Staff Assessment for Mental Status C0700 Short-term Memory OK C0800 Long-term Memory OK C0900 Memory/Recall Ability C1000 Cognitive Skills for Daily Decision Making C1300 Signs and Symptoms of Delirium (from CAM ) Inattention Disorganized thinking Altered level of consciousness Psychomotor retardation Code 0, behavior not present Code 1, behavior continuously present, did not fluctuate Code 2, behavior present, fluctuates 11

12 C1600 Acute Onset Mental Status Change Review medical record prior to the 7-day look-back period Interview resident s family or significant others. Code 0, no if there is no evidence of acute mental status change from the resident s baseline. Code 1, yes if resident has an alteration in mental status observed in the past 7 days or in the BIMS that represents a change from baseline. Section D D0100 Should Resident Mood Interview Be Conducted? Code 0, no (resident rarely/never understood, or who need an interpreter but one was not available) Code 1, yes (resident is able to be understood, and for whom an interpreter is not needed or is present) Section D D0200 Conduct the Interview Over the last 2 weeks, have you been bothered by any of the following problems? Read each item as it is written: Do not provide definitions because the meaning must be based on the resident s interpretation. Each question must be asked in sequence to assess presence and frequency before proceeding to the next question. 12

13 Section D D0200 Conduct the Interview For a yes response, ask the resident to tell you how often he or she was bothered by the symptom over the last 14 days. In column 1 enter 9 for a nonsensical response and leave column 2 blank Section D D0200 Coding Guidelines The look-back period is 14 days. Conduct the interview preferably the day before or day of the Assessment Reference Date (ARD). Code the higher frequency if resident has difficulty selecting between two options. Some items contain more than one phrase. If a resident gives different frequencies for the different parts of a single item, select the highest frequency as the score for that item. Section D D0300 Total Severity Score Add the numeric scores across all frequency items in Resident Mood Interview (D0200) Column 2. 13

14 Section D Complete/Incomplete Interview The interview is successfully completed if the resident answered the frequency responses for at least 7 of the 9 items. If the symptom frequency is blank for 3 or more items, the interview is deemed not complete. Code the Total Severity Score as 99. Complete the Staff Assessment of Resident Mood. Section D D0350 Safety Notification Complete this item only if D0200I1is coded 1. D0500 Staff Assessment of Resident Mood Look-back is 14 days. Interview staff from all shifts who know the resident best. If frequency cannot be coded because the resident has been in the facility for less than 14 days, talk to family or significant other and review transfer records to inform the selection of a frequency code. Section D D0600 Total Severity Score Add the numeric scores across all frequency items in Staff Assessment of Mood, Symptom Frequency (D0500) Column 2 The interview is successfully completed if staff members were able to answer the frequency responses to at least 8 out of the 10 items. D0650 Safety Notification Code this item only if D0500I Column 1 is coded 1. 14

15 Section E Behavior Focus on the resident s actions, not the intent of his or her behavior. Staff may have become used to the behavior. May under-report problematic behaviors. Minimize behavior by presuming intent. Section E E0100 Potential Indicators of Psychosis Hallucination Perception of the presence of something that is not actually there. May be auditory or visual or involve smells, tastes or touch. Delusion Fixed false belief not shared by others that the resident holds even in face of evidence of the contrary. Section E E0100 If a belief cannot be objectively shown to be false, or it is not possible to determine whether it is false, do not code it as a delusion. If resident expresses a false belief but easily accepts a reasonable alternative explanation, do not code it as a delusion. If the resident continues to insist that the belief is correct despite an explanation or direct evidence to the contrary, code as a delusion. 15

16 Section E E0200 Behavioral Symptom Presence & Frequency Assess the presence of the behavior only. Do not consider the intent of the behavior. Section E E0200 Categories of Symptoms A. Physical behavioral symptoms directed toward others B. Verbal behavioral symptoms directed towards others C. Other behavioral symptoms not directed toward others Section E E0200 Coding 0 Behavior not exhibited 1 Behavior of this type occurred 1 to 3 days 2 Behavior of this type occurred 4 to 6 days, but less than daily 3 Behavior of this type occurred daily 16

17 Section E E0200 Assessment Guidelines Code based on whether the symptoms are present. Do code based on any interpretation of the meaning or cause of the behavior. Code as present, even if staff have become used to the behavior or view it as typical or tolerable. Section E E0300 Overall Presence of Behavioral Symptoms Review the coding for E0200 Confirm if any items are coded 1,2 or 3 If any E0200 options are coded 1, 2 or 3 complete E0500 and E0600 Section E E0500 Impact on Resident Did any of the identified symptom(s): A. Put the resident at significant risk of physical illness or injury? B. Significantly interfere with the resident s care? C. Significantly interferes with the resident s participation in activities or social interactions? 17

18 Section E E0600 Impact on Others Did any of the identified symptom(s): A. Put others at significant risk for physical injury? B. Significantly intrude on the privacy or activity of others? C. Significantly disrupt care or living environment? Section E E0500 & E0600 Assessment Guidelines Consider all behavioral symptoms coded in E0200 Staff should use clinical judgment in determining i the significance ifi of the behavior for each resident. Section E E0800 Rejection of Care It is really a matter of resident choice. When rejection/decline is first identified, the team investigates and determines the rejection/decline of care is really a matter of resident s choice. Education is provided and the resident s choices become part of the plan of care. On future assessments, this behavior would not be coded in this item. 18

19 Section E E0800 Rejection of Care Residents who have made an informed choice about not wanting a particular treatment, procedure, etc. should not be identified as rejecting care. Section E E0900 Wandering Presence & Frequency Wandering is an act of moving from place to place without a specific course or known direction. May or may not be aimless May be oblivious to physical or safety needs May be oblivious to physical or safety needs May be for a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. May or may not be driven by confused thoughts or delusional ideas Section E E1000 Wandering- Impact Complete this item only if E0900 is coded 1, 2 or 3. Determine the impact of these behaviors. Put the resident at significant ifi risk of getting into potentially ti dangerous places. Whether wandering significantly intrudes on the privacy or activities of others Determine significance based on clinical judgment for the individual resident. 19

20 Section E E1100 Change in Behavior or Other Symptoms Review responses provided to items E0100- E1000 on the current MDS assessment Compare with responses provided to prior OBRA or scheduled PPS MDS assessment Make a global assessment of the change in behavior from the most recent to the current MDS Rate the overall behavior as same, improved or worse Section E E1100 Change in Behavior or Other Symptoms Using clinical judgment, rate the overall direction of behavior change, estimating the net effects of multiple behaviors Section F Preferences for Customary Routines and Activities Ask about current preferences while in the nursing home. Complete the interview anytime within the 7-day look- Complete the interview anytime within the 7 day look back period. Family or significant others can provide information on current preferences. Incomplete interview: nonsensical responses or fails to respond to 3 ore more if the 16 items in F0400 and F

21 Section F F0300 Should Interview for Daily and Activity Preferences be Conducted? F0400 Interview for Daily Preferences F0500 Interview for Activity Preferences Section F Interview for Daily Preferences and Activity Preferences 1. Very important 2. Somewhat important 3. Not very important 4. Not important at all 5. Important, but can t do or no choice. 9. No response or non-responsive Section F F0600 Daily and Activity Preferences Primary Respondent Establishes the source of the information regarding the resident s preferences. F0700 Should the Staff Assessment of Daily and Activity Preferences Be Conducted? If the total number of unanswered questions in F0400 through F0500 is equal to 3 or more, the interview is considered incomplete. 21

22 Section F F0800 Staff Assessment of Daily and Activity Preferences Observe the resident when care, routines, and activities are made available. Check any items for which the resident appears happy, content, or involved. Do not check any items for which the resident is resistant or withdraws. Section Q Q0100 Participation in Assessment A. Resident participated in assessment B. Family or significant other participated in assessment Spousal, kinship (e.g. sibling, child, parent, nephew) or in-law relationship; a partner, housemate, primary community caregiver, or close friend. Significant other does not include nursing home staff. Section Q Q0100 Participation in Assessment C. Guardian or legally authorized representative A person who is authorized, under applicable law, to make decisions for the resident, including ggiving gand withholding consent for medical treatment. 22

23 Section Q Q0100 Participation in Assessment While family, significant others, or, if necessary, the guardian or legally authorized representative can be involved, if the resident is uncertain about his or her goals, the response selected must reflect the resident s perspective if he or she is able to express it. Section Q Q0300 Resident s Overall Expectation A. Resident s overall goal established during assessment process 1. discharged to community 2. remain in this facility 2. remain in this facility 3. discharged to another facility/institution 9. Unknown or uncertain Section Q Q0300 Resident s Overall Expectation B. Indicate information source for Q0300A 1. resident 2. family or significant other 3. guardian or legally authorized representative g g y p 9. none of the above 23

24 Section Q Q0400 Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? Section Q Q0490 Resident s Preference to Avoid Being Asked Question Q0500B Does the resident s clinical record document a request that this question be asked only on comprehensive assessments? Section Q Q0500 Return to Community B. Ask the resident (or family or significant other if resident is unable to respond) Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? 24

25 Section Q Q0500 Return to Community Current return to community questions may upset residents that cannot go home and result in them being agitated or saddened by being asked the question. If the level of cognitive impairment is such that the resident does not understand Q0500B, a family member, significant other guardian and/or legally appointed decision maker for that individual could be asked the question. Section Q Q0550 Resident s Preference to Avoid Being Asked Question Q0500B Again A. Does the resident (or family or significant other or guardian, if resident is unable to respond) want to be asked about returning to the community on all assessments? B. Indicate information source for A0550A Section Q Q0600 Referral Document whether a referral has been made to a local contact agency. 25

26 Section Q If resident wants to speak to someone regarding services available in the community Complete the Nursing Home Discharge Planning Checklist Discharge Planning When the facility anticipates discharge a resident must have a discharge summary that indicates: A recapitulation of the resident s stay A final summary of the resident s status A final summary of the resident s status A post-discharge plan of care Section Z Z0400 Persons participating in assessment Title Sections contributed to Date of assessment Read the attestation statement carefully Nursing homes may use electronic signatures: If permitted by state and local law Authorized by nursing home policy 26

27 CAA(s) The MDS is a starting point. The CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident s functional status and related causes of impairments. Triggering a Care Area Assessment Care Area Trigger (CATs) Provide a flag for the IDT members, indicating that the triggered area needs to be assessed more completely prior to making care planning decisions. All triggering care areas are available on the MDS 3.0 item set except for: Delirium Mood State CAA(s) The CAA process does not mandate any specific tool for completing the further assessment of the triggered areas, nor does it provide any specific guidance on how to understand or interpret the triggered areas. Facilities should identify and use tools that are current and grounded in current clinical standards of practice, such as evidencebased or expert-endorsed research, clinical practice guidelines, and resources. 27

28 CAA(s) CAA Documentation Helps to explain the basis for the care plan by showing how the interdisciplinary team determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident. CAA(s) Documentation Should describe: Causes and contributing factors Nature of the issue or condition. Complications affecting or caused by the care area for this resident Risk factors related to the presence of the condition that affects the staff s decision to proceed to care planning. Factors that must be considered including appropriate documentation to justify the decision to plan care or not to plan care various findings for the resident. CAA(s) Documentation Should describe: Need for additional evaluation by the attending physician and other health professionals, as appropriate; Resource(s), or assessment tool(s) used for decision-making, and conclusions that arose from performing the CAA; Completion of Section V 28

29 Care Plans Comprehensive care plan an interdisciplinary communication tool. must include measureable objectives and timeframes must describe the services that are to be furnished to attain or maintain the resident s highest practicable physical, mental, and psychosocial well-being. must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident s written plan of care. Care Plan Goals The goal statement should include: the subject (first or third person), the verb, modifiers, and the time frame and the goal(s). Example Mr. Jones or I (subject) will walk (verb) fifty feet daily with the help of one nursing assistant (modifiers) for the next 30 days. (time frame) In order to maintain continence and eat in the dining room (goal) Care Plan Approaches Instructions for resident care and provide for continuity of care by all staff. 29

30 Care Plan Evaluation The effectiveness of the care plan must be evaluated from its initiation and modified as necessary. Changes to the care plan should occur as needed in accordance with professional standards of practice and documentation (e.g., signing and dating entries to the care plan). RUG-IV Behavioral Symptoms & Cognitive Performance Cognitive impairment BIMS score < 9 or CPS > 3 ll i i Hallucinations Delusions Physical behavioral symptoms toward others RUG-IV Behavioral Symptoms & Cognitive Performance Verbal behavioral symptoms toward others Other behavioral symptoms not directed toward others Rejection of care Wandering 30

31 RUG-IV Depression Used as an end split for several categories: Special Care High, Special Care Low, Clinically Complex PHQ-9 or PHQ-9-OV Total severity score 10 or > D0300 or D0600 Quality Measures Short stay: been in the facility less than or equal to 100 days Long stay: been in the facility 101 days or more Days do not need to be consecutive but are cumulative Quality Measures Percent of Residents Who Have Depressive Symptoms (Long Stay) (target assessment) Numerator Long-stay residents with a selected target assessment where the target assessment meets either of the following two conditions: Condition A(the resident mood interview must meet Part 1 Condition A(the resident mood interview must meet Part 1 and Part 2 below)» Part 1» Little interest or pleasure in doing things half or more of the days over the last two weeks is equal or greater than two (D0200A2= 2 or 3) or» Feeling down, depressed, or hopeless half or more of the days over the last two weeks (D0200B2=2 or 3)» Part 2» The total severity score (D0300>10 and <27) 31

32 Quality Measures Condition B: The staff assessment of resident mood must meet Part 1 and Part 2 below» Part 1» Little interest or pleasure in doing things half or more of the days over the last two weeks is equal or greater than two (D0500A2= 2 or 3) or» Feeling down or appearing depressed, d or hopeless half or more of the days over the last two weeks (D0500B2=2 or 3)» Part 2» The staff assessment total severity score indicates the presence of depression (D0600> 10 and D600 < 30) Exclusions Resident is comatose or comatose status is missing Quality Measures Percentage of long-stay residents who are receiving psychoactive drugs but do not have evidence of psychotic or related conditions in the target period. (target assessment) Target dates on or before 3/31/2012 N0400A=1 Target dates on or after 4/1/2012 N0410A= 1,2,3,4,5,6,7 Exclusions Schizophrenia I6000 Psychotic disorder I5950 Manic depression (bipolar disorder) I5900 Tourettes syndrome I5350 Huntingtons disease I5250 Hallucinations E0100A Delusions E0100B Quality Measures Percentage of long-stay residents who are receiving antianxiety medications or hypnotics but do not have evidence of psychotic or related conditions in the target period. (target assessment) Target dates on or before 3/31/2012 N0400B=1 or N0400D=1 Target dates on or after 4/1/2012 N0410B = 1,2,3,4,5,6,7 or N0410D = 1,2,3,4,5, 6, 7 Exclusions Schizophrenia I6000 Psychotic disorder I5950 Manic depression (bipolar disorder) I5900 Tourettes syndrome I5350 Huntingtons disease I5250 Hallucinations E0100A Delusions E0100B Anxiety disorder I5700 Post traumatic stress disorder I

33 Quality Measures Percentage of long-stay residents who have behavior symptoms that affect others during the target period Behavioral symptoms directed toward others (E0200A =1,2,3), or Verbal behavioral symptoms directed toward others (E0200B= 1,2,3) or Other behavioral symptoms directed toward others (E0200C= 1,2,3) or Rejection of care (E0800= 1,2,3) or Wandering (E0900= 1,2,3) Survey List of all residents who are receiving or have received antipsychotic medications over the last 30 days. Minimum of 4 residents in the sample who over the past 30 days received or are receiving antipsychotic medications. 672 F108: With Intellectual Disability (ID) (Mental retardation as defined at (a)) or Developmental Disability (DD) F109: With documented signs and symptoms of depression 33

34 672 F112: With behavioral health care needs F113: Of the total number with behavior healthcare needs, those having an individualized care plan to support them. F114: Receiving health rehabilitative services for mental Illness (MI) and/or ID/DD 672 F133: Receiving psychoactive medications F134: Antipsychotic medications F135: Antianxiety medications y F136: Antidepressant medications F137: Hypnotic medications F143: Who have advance directives Psychoactive Medications with Absence of Condition 12. Antianxiety/Hypnotic Medication 13. Behavioral Symptoms Affecting Others or Self 14. Depressive Symptoms 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) 34

35 References RAI Manual and Quality Measure Manual Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS 30RAIManual.html 672/802 Enrollment-and- Certification/SurveyCertificationGenInfo/Downlo ads/survey-and-cert-letter pdf Carol Hill RN, BSN, C-NE, CDP, RAC-MT Hill Educational Services Inc Asberry Road Warrior AL Warrior, AL Phone: Fax: