THE ROLE OF THE CLINICAL
LEADERSHIP PROFESSIONAL WITH THE
MDS 3.0 ASSESSMENT PROCESS
‘EVERYTHING YOU NEED TO SUCCEED’
AND THEN SOME !
Leah Klusch, RN, BSN, FACHCA
ABOUT LEAH…
‘I FOCUS ON LEARNING, NOT TEACHING’
 Leah Klusch is the founder and the Executive Director of the
Alliance Training Center. As an educator and consultant, she has
extensive experience in presenting motivating programs on
operation issues for individual ownership groups, facility
managers, state, regional, and national associations
 Leah & Redilearning have partnered to provide an exclusive,
comprehensive MDS 3.0 Program available ONLINE and
accessible anytime! This program will be shown in this
presentation via a live demo!
Staffing changes in the MDS office
POTENTIAL
ISSUES
IMPACTING
CLINICAL
MANAGERS
RELATED TO
MDS 3.0
Changes in the IDT
Changes in policies and procedures
MDS completion issues  transmission issues 
validation issues  painful billing issues
What do our clinical staff need to learn about the new
assessment process, definitions and documentation.
Assessments out of compliance influence regulatory risk
and signal the survey process
AWARENESS & KNOWLEDGE ARE KEY
Know the
status of
these issues
in your
facility
The MDS manager
may be busy and
not want to
disclose all the
issues.
Interact with
the process
and the staff
Better to know the
truth than to be
surprised.
*If assessments are not correct, in sequence
and on time, they will not be validated and
the services can not be billed and the
facility may face regulatory risk.
EVALUATE HOW THE MDS 3.0 ASSESSMENT
PROCESS IS MANAGED
 MDS Assessments and management of the process is not a nursing
responsibility
 At the beginning of the process in 1987, the assessment was nursing
assigned and was not interdisciplinary
 Now the MDS 3.0 process is much larger than a clinical assessment and
the responsibilities of the MDS Manager are very operational and
interdisciplinary.
 Operational and clinical managers need to discuss the structure of the
assessment process, team members assignments and performance and
proper delegation of tasks as well as accountability.
 Payment and regulatory implications for Nursing Leadership
DO YOU KNOW…
How many MDS assessments
are done in your facility by the
day/month or by clinical units?
Types of assessments that are
being completed?
The members of the IDT that
are doing assessment tasks?
The number of interviews by
type that are being completed
by the day or week?
The number of submissions
that are not validated on the
first attempt?
The reason why assessments
are completed late – ask the
MDS Manager.
The impact of mistakes on the
MDS data set on payment for
the facility?
EVALUATING THE IMPACT OF MDS 3.0
Many Operational Staff Have NOT evaluated the impact of the
change to the new data set on operational stability.
They still believe the MDS process is a nursing task..
WRONG!
They never evaluated the accuracy and efficiency of the
MDS 2.0 - so they were loosing money before.
Data was not utilized properly by managers to assess outcomes,
track patterns of care or validate payment
EVALUATING THE IMPACT OF MDS 3.0
 Software should be able to generate many reports that will isolate
problems and identify patterns of care and outcomes
 Staffing habits and documentation tools were not substantiating
the data = big risk on audit.
 Staff didn’t have resources / training to complete assessments
accurately. This is a very important issue.
 Rehab services were not evaluated for documentation accuracy.
Now we have a new process, new data set and definitions in place,
which requires a change in the processes and knowledge base of our
staff and our documentation tools.
CHANGES NEEDED FOR A SUCCESSFUL ASSESSMENT AND
DATA BASE DEVELOPMENT PROCESS
• Operational and clinical leadership must manage the transition
to the MDS 3.0 and identify the changes necessary to minimize
payment and regulatory risk.:
Budgetary
Management
Decisions
Staff
Delegation
Policy
Changes
THE REALITY OF THE MDS 3.0
New database to identify care delivery patterns, services, resident
characteristics, payment triggers and outcome measures.
New format and structure to the assessment process including many
new assessment formats.
Completion time up 35%!! Many new tasks –interviews and new
documentation.
Changes in definitions that drive the documentation and regulatory
process.
New software for all providers with a larger data base and more
hardware requirements for efficiency. Training for managers.
THE TRANSITION TO THE MDS 3.0
Investment in training,
resource materials and
support services.
New tasks and
schedules for data
collection and
reporting.
Payment system
change with more
complex data
processes and
frequent payment loss
for providers.
New QI/QM data base
to be released after
the system is in place.
April 2011
THE TRUTH ABOUT THE MDS 3.0
 Revised ADL scoring and calculation as well as ADL ranges..
(Now 0 - 16 ADL scale) New definitions Section G
 Increased regulatory definition..
 Section J – Falls
 Section P – Restraints
 Section H – Toileting programs
 Staff awareness and documentation formats must be revised to
fit the assessment process.
 New payment system for Part A Medicare with new
qualifiers and many changes in groupers.
MANY OF THESE
CHANGES REQUIRE YOU
TO LOOK AT YOUR
PROCESSES, FORMS,
POLICIES AND PROGRAMS
WHAT PAIN
ARE YOU
FEELING
NOW?
1, Are the assessment documents being.
completed, transmitted and validated on
time? This is a big risk
2. Software performance – Is your new
MDS 3.0 software functioning and
tracking assessment data properly? Can
you retrieve data for reports?
3. Is the staffing that you currently have
for assessment tasks adequate? Who
has had specific training?
WHAT PAIN
ARE YOU
FEELING
NOW?
4. Have you projected the changes to
the payment rates or payment
groupings that will occur after the
transition. Evaluate RUG distribution
not just total revenue.
5. What changes will impact your
Medicaid payment rates – case mix.
6. Have there been staffing changes?
How are you managing the training of
new staff and front line professionals?
Training deficit will be expensive –
Keep records of competency and
training.
LETS LOOK AT THE ISSUES FROM A 40,000 FOOT
VIEWPOINT..
• CMS has created a new assessment process and data base that
connects to a new Medicare payment system.
• The purpose for many of the changes is to improve oversight
and reduce payment to the facilities…
OUCH!!
• The new process requires all new resource and processing
systems which send data to a central server for validation,
processing and storage.
THIS REQUIRES PREPARATION AND PROACTIVE
MANAGEMENT
CMS did not handle the
transition to the new process
well
Training began in April and has
been continuous until now –
training must continue.
The manual and process
changed in that time requiring
retraining and new resources.
The transition has required
investment and budget.
Leadership and problem
solving has been necessary
from many levels.
Monitoring of the data process
and support to the staff doing
the assessments is necessary.
STAFF SUPPORT IS CRUCIAL
2. Understand that training
does not mean learning…
1. Know who the primary
players in the assessment
and documentation process
are
• Do they understand what they
need to do and have the support
from the IDT and operational
staff to complete the
assessments on time –
correctly..?
Much of the early training was
incomplete
Many changes after July 2010.
Training with competency
testing is the best.
Document training – specifics.
PRIMARY
STEPS
Identification of
the assessment
activity in the
facility is essential.
Medicare and
Other assessments
need to be tracked
to monitor the
process for
efficiency and
accuracy.
Who is involved in
the data collection
and formulation
process as well as
transmission and
billing.
Evaluation of
Compliance – Very
important- Who
knows the rules?
Who uses the
manual.
MANUALS MUST BE IN NUMEROUS
LOCATIONS IN THE FACILITY AND BE
A CENTRAL REFERENCE FOR STAFF
UNTIL THEY ADAPT TO THE NEW
DEFINITIONS AND ASSESSMENT
PROCESS.
QUESTIONS TO ADDRESS
Who is managing the RAI or assessment
process in the facility?
What is their training, preparation , and
understanding of the process and its
requirements?
Ask them what the changes are that they
are dealing with – you may be surprised
with the answer you get.
Who is doing interviews? What is their training
and where are they documented in the record?
• Interviews must be conducted using the Steps for
Assessment in the RAI Manual. Check it out.
MANAGING PAYMENT
How do you manage and document RUGs
distribution – prior to 10-01-10 and after?
What are the predictable changes and the real
changes in RUG groupers and payment levels.
Do you understand RUG IV payment and the
changes in the CMI levels , payment levels and
ADL coding?
ADL CHANGES – BIG DEAL!
Changes will be seen in:
1. Definitions
2. Total number of codes utilized for calculation of the
ADL score.
3. The calculator – new values and lower ADL scores
for common levels of support.
4. New ADL ranges for payment categories.
HOW ACCURATE ARE YOUR ADL SCORES?
Are they
documented in the
record?
How about those
interviews with
staff?
START AT THE SOURCE
 What is the documentation behavior of your front line care
givers?
 History, Forms, & Formats
 Just imagine they had the CMS checkbook and were writing the
facilities reimbursement checks…Far fetched? NO!
 Do you know the ADL scores for your Part A Medicare cases and
your total census?
 How about ADLs for Rehab cases – over time!
 Are ADL scores discussed at the Medicare Meeting?
 This is necessary!
A FEW FACTS ABOUT ADL SCORES
All MDS data sets create an ADL score for that resident
during the assessment reference period.
ADL scores distribute payment within payment
categories.
ADL calculation from the MDS 2.0 system to the MDS
3.0 system has been changed resulting in lower
relative scores.
2.0 TO 3.0 ADL SCORE CALCULATION
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed Mobility
2
2
ADL Pts 3
Bed Mobility
2
2
ADL Pts 1
Transfer
2
2
ADL Pts 3
Transfer
2
2
ADL Pts 1
Eating
1
1
ADL Pts 1
Eating
1
1
ADL Pts 0
Toilet Use
2
2
ADL Pts 3
Toilet Use
2
2
ADL Pts 1
Total ADL Score = 10!
Total ADL Score = 3!
2.0 TO 3.0 ADL SCORE CALCULATION
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed Mobility
3
2
ADL Pts 4
Bed Mobility
3
2
ADL Pts 2
Transfer
3
2
ADL Pts 4
Transfer
3
2
ADL Pts 2
Eating
1
2
ADL Pts 1
Eating
1
2
ADL Pts 2
Toilet Use
3
2
ADL Pts 4
Toilet Use
3
2
ADL Pts 2
Total ADL Score = 13!
Total ADL Score = 8!
2.0 TO 3.0 ADL SCORE CALCULATION
MDS 2.0 ADL Calculation
MDS 3.0 ADL Calculation
Bed Mobility
3
3
ADL Pts 5
Bed Mobility
3
3
ADL Pts 4
Transfer
3
3
ADL Pts 5
Transfer
3
3
ADL Pts 4
Eating
1
1
ADL Pts 1
Eating
1
1
ADL Pts 0
Toilet Use
3
2
ADL Pts 4
Toilet Use
3
2
ADL Pts 2
Total ADL Score = 15!
Total ADL Score = 10!
WHAT IT MEANS FOR YOU…
First you must identify the documentation
process and the requirements of ADL
performance and support provided by your
staff to determine if the ADL scoring in the
MDS data set is accurate
Second you must monitor ADL levels in the
facility data base and on a case by case
basis.
IMPORTANT QUESTIONS..
1. Which members of your IDT and Rehab staff
understand the formation and use of ADL scores?
2. How are ADL scores reported to the team and
utilized during Medicare coverage discussions?
3. What specific impact do ADL scores have on
payment levels in the RUG IV payment system?
4. Do any members of your team clinical or financial
document ADL scores on RUG distribution reports?
1. This is essential documentation!
WHAT IT MEANS FOR YOU…
 Is ADL documentation training included in all front line staff
orientation with competency testing?
 Do front line staff use electronic point of care documentation
systems correctly? You should hear the stories!
 Since ADL scores drive payment – up to $100 per day –could
your ADL codes on the MDS withstand audit?
 Reproducible documentation is REQUIRED by the regulation
 Are any ADL performance scores or support coded from staff
interviews? Big Problem!
STEPS TO YOUR SOLUTION
Identify the problem
Front line documentation must be accurate during the
ARP – 24/7
Accountability is necessary
You need to know the quality of your coding first and
then focus on correcting the errors and incomplete
documentation.
STEPS TO YOUR SOLUTION
 Key members of the data collection, processing and billing
team must have a complete understanding of the
processes, rules and definitions.
 Who Reads and Understands the RAI Manual?
 Communication within this team is essential as well as
regular contact for problem solving.
 Software must be integrated so data is moved seamlessly
between the data collection, MDS Data Set, transmission
and billing processes.
BE CAREFUL WITH MINUTES!
 The minutes of therapy that are documented on the MDS
are attested to for accuracy according to the rules in the RAI
manual. Does this correspond with therapy staffing levels?
 People who code minutes of skilled therapy need to code
the type of minutes delivered with each treatment. Be VERY
Careful!
 Total minutes of delivery are not necessarily billable to the
RUG.
 Operational Leadership needs to visit and observe the
therapy department
RESOURCES FOR OPERATIONS
RAI manual Chapter 3 – Section O – Pages 14 to 24.
Skilled therapy definition and coding minutes of
therapy directions.
RAI Manual Chapter 6 – Payment System pages 19-21
– September 2010 update – calculation of billable
minutes from total minutes.
Example in the manual can be entered into therapy
software to check that calculations are correct.
RESOURCES FOR OPERATIONS
 Have therapy show you how the minutes are documented in their
records – which go into the medical records – and then how the
minutes are collected for the MDS and tracked for payment levels
 These are three separate tasks which have all been adapted or
changed in the new process.
 Problems include the reduction of concurrent and possibly group
minutes.
 THERAPY SIGNS THE MDS ATTESTATION FOR THERAPY MINUTES.
 Monitoring is essential – IT IS YOUR RISK !
WHAT HAPPENS IF WE GET THIS WRONG?
 Validation may be difficult or not possible, and without validation, the MDS is not
complete.
 Unexpected delays or reduction in payment or default rates – none of which is
advisable
 The facility assessment process can be out of compliance impacting payment and
producing citations or audits.
 New Survey and Cert letter telling surveyors how to monitor compliance – no
forgiveness here even though CMS was not processing.
 The data base for the facility can be wrong impacting PAYMENT AND
COMPLIANCE. THAT MEANS AUDITS AND SURVEY ACTIVITY.
STEPS TO TAKE
1. The MDS process is operational, change the
structure if necessary and manage it carefully
2. Look at the assessment activity – the numbers, the
time lines for validation and the efficiency of the
process.
3. Is the data base accurate – if not – why not?
4. Inaccurate data reduces payment.
5. Review RUG distribution with ADL scores
KEY POINTS TO REMEMBER
 Look at the MDS office for efficiency, and work space quality.
 Monitor wasted time in the data entry process
 What resources does the MDS manager need to complete the assessments?
 Meet with the MDS Manager weekly to discuss assessment activity,
documentation issues and data flow.
 Identify the communication between the MDS office and billing as well as
the software performance in these areas.
 Check the compliance of the billing process
 Map out the data transfer process for late month Part A admissions.
CLINICAL MANAGERS HAVE A
SIGNIFICANT RESPONSIBILITY IN THE
PROPER IMPLEMENTATION OF THIS
INTERDISCIPLINARY FUNCTIONAL
ASSESSMENT TOOL AND THE REVIEW
OF THE DATA BASE IT CREATES.
What data do you need reported ?
 REMEMBER THE SURVEY AND PAYMENT TEAMS HAVE ALL THE DATA
AND VERY SOPHISTICATED SOFTWARE TO PULL OUT SPECIFICS THAT
RELATE TO THEIR PROCESS.
 WHAT DATA ARE YOU MONITORING – LIKE FALLS WITH INJURY EXCEPT
MAJOR, WANDERING, REFUSAL OF CARE, SIGNIFICANT BEHAVIOR
OUTCOMES, ADL SCORE CHANGES, SHIFT OR CHANGES IN BIMS AND
MSS SCORES…………….
 HOW DOES THE DATA SET REPRESENT THE FACILITY AND ITS SERVICES
AS WELL AS THE OUTCOMES FOR ITS ELDERS? VERY IMPORTANT
QUESTION.
THANK YOU!
QUESTIONS???????????
 Presented by
 Leah Klusch
 Executive Director
 The Alliance Training Center
 330-821-7616
 leahklusch@sbcglobal.net