Very few directors of nursing (DONs) learned anything about the MDS during their advanced preparation for the clinical management role. The MDS is never mentioned during interviews or orientation for the DON position. But it is important for the DON to have at a least a cursory understanding of the MDS assessment process.
The importance of the MDS assessment to the organization cannot be overstated. Though the MDS is often viewed as a reimbursement tool, the implementation of the MDS Focused Surveys by the Centers for Medicare & Medicaid Services (CMS) has altered its status for the provider organization. The surveys will examine the correlation and coordination of the medical record documentation with the MDS assessment coding and the care plan’s representation of the coded items. The original intent of the MDS assessment was as a tool to document resident care information that is translated into a plan of care to be used by the team caring for the resident. That intent remains in effect.
How does the DON relate to the MDS assessment? The DON faces a barrier if trying to manage a team of nurses with responsibilities that he or she does not understand. While we all agree that managers do not have to know everything there is to know about all areas for which they have direct responsibility, they need to have some degree of comfort with the MDS process or they cannot be of assistance to the team they’re managing. Support is the most critical thing the DON can provide for the assessment nurses to ensure that the assessment office operates effectively and efficiently. This support may require actions such as an evaluation of staff functions, possible redistribution of the workload, provision of the most current MDS manuals, and opportunities for additional MDS staff training.
The assessment nurses are experts in ensuring supporting documentation for MDS coding from all parts of the medical record, including activities of daily living (ADLs). This combined documentation supports the Resource Utilization Group (RUG) outcome derived from the MDS coding included on the UB-04 claim for billing of services. Audits by external review organizations—Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs), as well as managed Medicare payor audits, subject the claims to increased scrutiny, which requires supportive documentation in the medical record. The DON is in a unique position to bring together the assessment nurses and care nurses to strengthen the support documentation. The nurse assessment coordinators can educate the nursing assistants about ADLs, including the components and the self-performance and support codes. Education for licensed nurses can address items that meet significant change criteria and the support documentation needed for items of care and service to be coded on the MDS.
Medical record documentation is required before items can be coded on the MDS. That same documentation is required to support the delivery of care and services to residents. It is a symbiotic relationship found in documentation. Whether nursing leadership elects to utilize a form or narrative notes for the medical record documentation, it is reasonable that the documentation reflect the MDS items in representing the care and services delivered to the residents. The items included in the MDS assessment tool are significant in the care delivery for residents. Shortness of breath on exertion and when lying flat, or pain that interrupts sleep or prevents participation in activities, is a clinical care item that should be included in documentation and in the individualized care plan and should drive the plan of care. Coordinating both the care items that support the MDS coding and the delivery of high-quality resident care is a synchronization role for the DON. In this role as coordinator of medical record documentation, the DON supports the regulatory compliance that will be evaluated during the annual licensure and certification survey and MDS Focused Surveys, as well as the care and service delivery that can be coded on the MDS and accurately reimbursed.
Coding the MDS requires diagnosis and support for the fact that the diagnosis is active. Physicians are required to support the active status of the diagnosis in their documentation, and the nurses who work closely with them make the medication requests that, with diagnosis attached, additionally support the active status. Focus on the active diagnoses can also prove helpful to the DON in preventing avoidable rehospitalizations.
Accurately documenting ADLs is critical not only for the accuracy of the RUG classification but, more importantly, for ensuring that the level of assistance required by residents is communicated. This documentation is of interest to the DON because there must be justification for a referral to rehabilitation therapy services and/or to restorative nursing services for residents demonstrating improvements or declines in ADLs. The DON needs to know that the ADL support is documented, that residents are receiving the ADL services needed, and that based on the nursing assistants’ documentation of ADL support, residents are provided the appropriate staffing levels as justified by that documentation.
The possibilities are endless for the involvement of the director of nursing with the MDS assessment and the complete Resident Assessment Instrument (RAI) process. Every step in the process is something that will assist the DON with clinical initiatives such as Quality Measures improvement, prevention of rehospitalizations, care plan and plan of care management, and preparation for licensure and certification surveys and the MDS Focused Surveys. Most significantly, the correlation of the MDS assessment with the role of the DON ensures that the residents are receiving the quality care and services they need for their highest practicable quality of life.
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