With Minimum Data Set (MDS) Focused Surveys in full swing it is imperative that you have your survival plan in place. This will ensure when the surveyors enter your building you will be prepared. MDS focused surveys were implemented to assess MDS coding practices and identify MDS coding errors. It is more important than ever that your MDS’s are done accurately and timely.
Let’s take a closer look at the high risk areas:
Minimum Data Set Focused Surveys
Pressure Ulcers - The pressure ulcer questions inSection M of the MDS have a high rate of error. The majority of the errors occur in the staging of wound in M0300. When staging a wound you must use the definitions provided in the RAI manual.
Falls - The falls questions in Section J are another area of high errors. In order to accurately complete this section you will need to make sure you are correctly counting the number of falls and you must use the definitions provided in the RAI manual when determining major injury, injury, and no injury. Make sure to pay special attention to the look back periods on these questions.
Medications - Section O requires the counting of medications in the lookback period. This seems like a pretty simple section but the medications are frequently miscounted. Be sure that you are looking at the correct lookback period when you are reviewing your medications. Also ensure that you are looking at the routine, PRN, and one (1) time medications in order to make certain you end up with a correct total for each category. You will also need to make sure that you know the classifications for all medications given. There are a lot of new medications out there, and it is easy to overlook. For example, did you know that Compazine is antipsychotic?
ADL’s - It is important to include as many disciplines as possible in the calculation of Section G of the MDS. Interviewing your staff on all shifts is imperative to accurate coding. Another common mistake is assuming that the data that has been imported is accurate. Having the STNA/CNA data imported into the MDS is a great feature, but this does not mean you can assume that it is correct. It is the MDS nurses responsibility to validate the accuracy of data that has been pulled into to every assessment.
Diagnosis -When completing the Section I of the MDS the RAI manual tells us to include active diagnoses so it is important that you accurately determine the active diagnoses. You should start by reviewing the medical record: progress notes, H & P, transfer documents, discharge summaries, diagnosis list, nursing assessments, medication sheets, treatment sheets, doctor’s orders, consults, diagnostic reports, and any other resources available. In order for you to include a diagnosis as an active diagnosis, you are required to have the diagnosis documented by authorized licensed staff as dictated by state law.
Restraints - When coding items in Section P of the MDS, the most important thing to remember is: does the device meet the definition: “Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body “(State Operations Manual, Appendix PP) (RAI Manual, Ch3: P1). Make sure there is also a completed restraint assessment for these devices.
There are multiple areas of the MDS that are considered high risk. By routinely auditing those areas you can increase the accuracy of the MDS and thereby decrease the number of potential citations. With planning and attention to detail you can survive!