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Survey and Section I: Diagnosis-Related Deficiencies

Long-term care leadership often observes that the nurse assessment coordinator (NAC) role calls for detail-orientation and strong time-management and assessment skills, because these nurses must coordinate the resident assessment that drives the care plan, quality measurements, and (at times) reimbursement. While NACs strive for accuracy and integrity in this process, mistakes happen. If those mistakes are identified during a survey, they can result in a deficiency tag. Deficiencies can be cited for a multitude of MDS-related reasons, from untimely scheduling to late submission, and almost everything in between—including the accuracy of the MDS. This broad focus considers the accuracy of every single section of the MDS, from A-to-Z. This article will focus on some recent deficiencies cited because of inaccuracies in Section I, Active Diagnoses, and some tips on how to avoid these diagnosis-related deficiencies.

Frequently, diagnosis-related deficiencies are identified when the MDS assessment fails to reflect the accurate diagnosis. In this case, F-Tag 641, Accuracy of Assessments, is cited. The State Operations Manual (SOM) guidance in appendix PP states that the intent of the regulation is “to ensure that each resident receives an accurate assessment, reflective of the resident’s status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident’s status, needs, strengths, and area of decline.” When a facility receives a deficiency during a survey, this information is released to the public through the CMS-2567, description of noncompliance, with all personal identifying information removed. The citations reviewed in this article were issued between April and September 2021.

Complete a thorough review of physician-documented diagnoses in the last 60 days.

The key to accuracy of diagnoses on the MDS is that they must meet two criteria: (1) be documented by a physician (or non-physician practitioner as allowed by state law) in the last 60 days and (2) be active in the 7-day look-back period. However, a review of the CMS-2567 reports shows that facilities are being cited with F-Tag 641 for failure to include all active diagnoses on the MDS. For example, one facility received a deficiency after surveyors noted that although congestive heart failure (CHF) was noted on the face sheet at the time of admission and documented by the nurse practitioner during a visit in the last 60 days, CHF was not included on the resident’s master list of diagnoses and was not coded on the most recent MDS assessment. Furthermore, the resident’s care plan revealed no documentation of the resident’s CHF diagnosis.

In a different facility survey, interview and record review revealed that the facility failed to ensure the assessment accurately reflected the resident’s diagnosis on a Significant Change in Status Assessment (SCSA). The resident was noted to have a physician-documented wound infection (not on the foot) in the last 60-days and received ongoing treatment in the look-back period, but MDS item I2500, Wound Infection (other than foot), was not coded.

In another facility, the NAC had mistakenly added a diagnosis to the resident’s MDS that was not physician-documented. While the resident had symptoms that supported that diagnosis, the coded diagnosis was not supported by physician documentation. For example, if a resident had documentation of memory and cognition symptoms, the NAC cannot assign a diagnosis of dementia without the physician documentation of this diagnosis. The surveyors noted in the CMS-2567 report that “any individual who willfully and knowingly certifies (or cause another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action.”

This reinforces the importance of accuracy in resident assessments. Not only do NACs need to carefully review the medical record for physician documentation of diagnoses in the last 60 days, but they also must be sure to code only diagnoses that meet the criteria: they must be documented by the physician as well as active in the past 7 days. If further specificity is needed, the facility staff must query the physician for clarification.

Monitor the diagnosis-medication connection.

Many items on the MDS are interrelated. Understanding these relationships, like the link between medications and the condition they are intended to treat, can help the NAC complete quick audits to ensure the accuracy of both the diagnoses and medications on the MDS. One way to ensure that a diagnosis meets the “active” criteria is to identify if a medication is currently being provided to treat the condition. For example, if depression is an active diagnosis and the resident is being treated with trazodone daily during the look-back period for depression, then this diagnosis is supported as active for MDS coding.

The CMS-2567 reports showed numerous instances when citations originated from inaccuracies in both diagnoses (section I) and medications (section N). At times, the diagnosis was documented in the medical record but was missing on the MDS. Yet there were also occurrences where the surveyors identified that a medication was not coded accurately on the MDS as they followed up on the treatment for a condition. One facility was cited F-Tag 641, with a scope/severity level of E, when a resident had a diagnosis of depression and received an antidepressant, but the medication was not correctly coded in section N.

A minor error can result in a major consequence.

The interrelation of MDS items means that when a coding mistake is made, it may impact far more than the erroneous MDS item itself. One facility experienced this during a survey in which it received a D level citation, F641, for failing to complete an accurate and complete assessment. The resident’s health history and diagnoses were not adequately acquired to appropriately manage the resident’s health conditions at the time of admission. The surveyor noted that since the staff was not fully informed on the resident’s condition, the resident could have experienced delays in care and decline in condition.

In another facility, surveyors noted a resident had compression stockings and diuretics ordered for treatment and complications of CHF during the 7-day look-back, as well as physician documentation of the diagnosis in the past 60 days. However, CHF was not coded in section I. Further review of the record uncovered a progress note that the resident had been found on the floor in his bathroom, but this fall was not noted on the MDS. When the surveyor looked further into this chart because of the first inaccuracy identified, it revealed additional issues.

A different facility received F641 because it failed to identify the need for a Level II PASSR during a SCSA for a resident with a serious mental illness. Even though this citation was not based on an inaccuracy in Section I, since the team failed to identify that the resident had a serious mental illness when completing a SCSA, they did not follow the RAI User’s Manual instruction that “a significant change may require referral for a Preadmission Screening and Resident Review (PASRR) evaluation if a mental illness, intellectual disability (ID) or related condition is present or is suspected to be present.”

Conclusion

The importance of having accurate diagnoses cannot be overstated. While this article focused on the survey implications of inaccurate diagnoses, there are also potential effects beyond the MDS and regulatory compliance. Diagnoses play a key role in quality measurement, usually by providing a risk adjustment or exclusion to the measure. Additionally, diagnoses affect the patient-driven payment model (PDPM) for Medicare reimbursement, and may also be used in some state Medicaid case-mix systems. But most importantly, diagnoses are a vital component of care planning. To ensure that all of the resident’s active conditions are being addressed and that the facility staff understand the resident’s goals and preferences for care for each condition, accuracy in coding Active Diagnoses is critical.

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