Revised Ftag of the Week – F641 Accuracy of Assessments (Pt. 2)

In Part 1 of our CMSCG Ftag of the Week series for F641 Accuracy of Assessments, we reviewed the regulatory requirements and guidance from the soon-to-be-obsolete F642 which are being relocated to F641. Those requirements are related to coordination and certification of assessments. The revised guidance to surveyors includes new investigative procedures which highlight how a referral to the OIG will be made if a pattern of inaccurate MDS coding is identified and there are concerns that the coder knew the coding was inaccurate. If you missed Part 1, you can check it out here.

---

---

Let’s look at what else you need to know about F641.

The regulation at F641 requires one final thing – that assessments accurately reflect the resident’s status. That’s a small sentence, but it’s got a lot of potential for problems, especially if you’ve got a survey team that’s well-versed in the MDS. 

• Accuracy requires that qualified staff use the appropriate RAI assessment and correctly document  resident strengths to maintain or improve functional abilities, psychosocial status and medical status.
•  The assessment needs to represent the resident’s status during the look-back period for each MDS item. Anything that occurs outside of the observation period is not coded on the MDS.

Revised Guidance to be Aware of

As mentioned in Part 1 of our Ftag of the Week for F641, much of the revised guidance to surveyors emphasizes a key concern of the Centers for Medicare and Medicaid Services (CMS) – MDS diagnosis coding, particularly as it relates to mental illness. Inaccuracies in Section I are something we routinely run across during medical record audits or during CMSCG Mock Surveys, but with the Schizophrenia Audits that have been taking place, there’s even more eyes watching to see if you’ve coded a resident with Schizophrenia.

Sure, in some cases, there are residents that have Schizophrenia or schizoaffective disorder and other mental illnesses, but in other cases, the lack of validating documentation related to Schizophrenia is where the problem arises.  What we have seen as a glaring issue that’s getting nursing homes in trouble during Schizophrenia Audits is that they didn’t do their “homework” about this diagnosis and took one mention from a hospital discharge paper that the resident has this diagnosis and then it’s added to the MDS. That’s one problem, but the area of focus for the guidance at F641 is really related to newly added Schizophrenia diagnoses. Remember, you’ve been submitting MDS assessments for the same individuals potentially for years, so when you add in a significant new diagnosis like Schizophrenia that wasn’t present on admission or multiple prior assessments, it shouldn’t be surprising that it’s going to raise red flags.

Now, we have clients where they did their homework and identified Schizophrenia that wasn’t initially identified on admission, but through discussion with the family and/ or representatives, other medical providers in the community or otherwise, were able to validate the diagnosis. That’s supposed to be a rule, not the exception, and unfortunately, it’s where many providers have found themselves in trouble. The revised Interpretive Guidance (IG) states that surveyors are expected to validate if the medical record contains supporting documentation of the diagnosis which verifies the accuracy of the assessment.

Supporting Documentation

Here’s the most important part of the revised guidance. If you’ve got residents coded with Schizophrenia, you need to be able to provide, at a minimum:

• Evidence of evaluation of the resident’s physical status, comorbid conditions, other medical conditions and changes to functional status, if any
• PASRR evaluation
• Evidence of evaluation of the resident’s mental, behavioral and psychosocial status (read: comprehensive psychiatric evaluation to validate the diagnosis)
• Evidence that the resident’s behaviors, indications of distress and symptoms have been evaluated
• Evidence that the physiological effects of a substance, whether a medication or drug, has been ruled out

It’s important to note that many providers can’t provide evidence of a comprehensive psych eval to validate that the resident has Schizophrenia versus something else. Surveyors are also guided to review several other tags if they aren’t able to find sufficient documentation, so the problem may not only result in one citation. You could potentially be exposed to citations at:

• F658 Services Meet Professional Standards (stay tuned for a revised Ftag of the Week!)
• F644 Coordination of PASARR and Assessments
• F841 Responsibilities of the Medical Director

The draft IG also lists F758 Free from Unnecessary Psychotropic Meds/ PRN Use as one of the tags to review, but don’t forget, F758 is being relocated to F605 Chemical Restraints with the revisions to the guidance.

Remember that CMS has previously indicated that the number of later-age diagnoses of Schizophrenia that it is seeing is unlikely, so expect that the Agency will continue to hammer away at the use of antipsychotics the way it has since it initiated the National Partnership to Improve Dementia Care and its initiative on behavioral health and antipsychotic medication reduction.