The document provides guidance from an OIG stakeholder meeting on documentation requirements for various sections of the MDS 3.0 assessment. Key points discussed include: all interviews in Sections C and D must be done on the assessment reference date or within a 7 day look back period; ADL documentation in Section G can include flow sheets but must not have conflicting information; diagnoses listed in Section I must be active and impact current care; restorative programs in Section O do not require physician orders but must have goals, interventions, and periodic evaluations; and respiratory therapy in Section O must be ordered by a physician and provided by qualified professionals according to defined standards. The document also addresses signature requirements, reconsideration timelines, and medical necessity reviews

1. OIG Utilization Review
Documentation
requirements for the
MDS 3.0
OIG Stakeholder Meeting March 24th

2. Section C and DSection C and D
InterviewsInterviews
Handout (Med Pass BIMS Interview)
All Interviews must be performed on the
ARD or in the 7 day look back
Documentation of the date this was
completed should be signed at Z0400 on
the date the interview was done
If not performed in the window will not
be counted as valid and therefore dashed
as undetermined at the OIG review

3. Section GSection G
Handout: DADS Provider Letter:
Nursing facility management must determine how ADL information is
documented. CMS, DADS and HHSC rules and regulations do not
mandate a specific form, format or template for ADL documentation. For
example, use of ADL flow sheets, electronic or paper, completed by
Certified Nurse Aides is acceptable supporting documentation for ADL
coding in Section G, as long as there is no conflicting information in the
rest of the clinical record. As noted on page 1-8 of the MDS 3.0 RAI
Manual, “While CMS does not impose specific documentation procedures
on nursing homes in completing the RAI, documentation that contributes
to identification and communication of a resident’s problems, needs, and
strengths, that monitors their condition on an on-going basis, and that
records treatment and response to treatment, is a matter of good clinical
practice and an expectation of trained and licensed health care
professionals. Good clinical practice is an expectation of CMS. As such, it
is important to note that completion of the MDS does not remove a
nursing home’s responsibility to document a more detailed assessment of
particular issues relevant for a resident.”
Furthermore, when the resident’s level of self-performance or the level of
support provided changes, supporting documentation in the clinical record
must accurately describe the change.

4. ADL DocumentationADL Documentation
When documentation is conflicting we must
provide an explanation of why there was a
change.
◦ Corrections to documentation errors should be
made according to policy and standards of practice.
Electronic ADL (Caretracker, Accunurse, Point
of Care, Etc.) documentation needs an Electronic
Signature policy
Must be able to determine who is documenting
on those forms
Handout: Therapy ADL documentation
crosswalk

5. Section ISection I
Active Diagnosis must impact the resident
current care in the look back period
(Aphasia)
Quadriplegia must be documented from a
spinal cord injury not functional
Diagnosis must be written by physician
within the last 60 days.
Should be recorded and signed on the
consolidated orders
Telephone orders initiated by nurse not
acceptable

6. Section OSection O
RestorativeRestorative
Certified nurse aides meet the criteria for
training for Restorative care if trained in Texas.
If programs are beyond the normal scope such as
specific splints or braces may require
individualized training
Must be able to show certification when asked
Program must have measurable goals and
interventions and clinically appropriate
Should be documented in care plan
Must be a periodic evaluation of the effectiveness
by a licensed nurse (OIG suggested monthly)
Does not require a physician order
Does not have to be written by a therapist

7. Section OSection O
Respirator TherapyRespirator Therapy
 Handout: MDS Mentor
 Must be ordered by a physician
 The physician’s order includes a statement of frequency,
duration, and scope of treatment;
 The services must be directly and specifically related to an
active written treatment plan that is based on an initial
evaluation performed by qualified personnel
 The services are required and provided by qualified
personnel (See Glossary in Appendix A for definitions of
respiratory therapies)
 The services must be reasonable and necessary for
treatment of the resident’s condition.
 A day of therapy is defined as treatment for 15 minutes or
more in the day.

8. Section OSection O
Respiratory TherapyRespiratory Therapy
Only include respiratory services that are
provided by a qualified professional to include:
◦ Respiratory therapists
◦ Trained Nurses following the nurse practice act
Methods of developing trained nurses:
◦ Training by a respiratory therapist
◦ Training by a RN who was trained by a respiratory
therapist
◦ Training by a RN who has advanced academic training
in respiratory therapy.

9. Section OSection O
Respiratory TherapyRespiratory Therapy
Training Curriculum:
◦ Should be titled, “Respiratory Therapy
Training” and not Nebulizer training.
◦ Maintain copy of training records in each
nurses file:
 curriculum used for training
 Evidence that nurse was trained by staff qualified to
provide the training. (trainers credentials and
training certificate or license)
 Competency checklist initialed by trainer and
trainee

10. Can a LVN Conduct RespiratoryCan a LVN Conduct Respiratory
Training: Reference MDS MentorTraining: Reference MDS Mentor
 A LVN who has demonstrated competency in providing
respiratory therapy services may train other LVNs to
provide respiratory therapy, using the following guidelines:
◦ The curriculum must be developed and approved by a certified
respiratory therapist, registered nurse, or physician trained to
provide respiratory therapy services. (The LVN may participate
in developing but cannot develop independently)
◦ Must demonstrate competency in training other LVNs. This
includes system to check:
 LVN competency in providing respiratory therapy, and;
 LVN competency in training other LVNSs
 Competency must be conducted annually

11. Z0500A and S4 of LTCMIZ0500A and S4 of LTCMI
RN signature at Z0500A and the license number
at S4 must be the same person
Can be used in LTCMI even if no longer
employed
Must have current RUG certification
Should keep copies of all RUG certifications in
employees files to produce to OIG reviewers
No penalty currently if not matching but will
consider in the future
LTCMI should be attached to the appropriate
MDS

12. ExtrapolationExtrapolation
MDS 2.0: Extrapolation amount is being
waived for providers that have open
cases and the error rate was 15% or less
◦ Contact Linda Carlson at 512.491.2065 or
linda.carlson@hhsc.state.tx.us if you have not
received
MDS 3.0: The OIG has decided not to
apply extrapolation to MDS 3.0 reviews
but have reserved the right to apply it in
the future.

13. Conference Call/AudioConference Call/Audio
Recording of OIG Exit:Recording of OIG Exit:
Facilities may choose to set up the exit
on a conference call to allow for other
interested parties to participate:
◦ Must be able to receive, sign, and return
Preliminary statement of findings.
◦ OIG will not conduct exit if provider
attorneys are on the conference until they
are able to coordinate with their attorneys to
join.
May record exit conference

14. Reconsideration Timelines:Reconsideration Timelines:
Reconsiderations must be post-marked
on or before the 15th
day of the telephone
exit conference:
We are seeking to have these timeframes
extended
Extensions may be granted on a case by
case basis. Contact Judy Knobloch at
512.491.2070 for extension request.

15. Medical Necessity ReviewsMedical Necessity Reviews
Currently reviewing PA1 and PA2s
Are making determinations even if the
recipient had Permanent Medical Necessity
Legislature asked DADS to conduct a
Medical Necessity Review
◦ Independent review conducted in 2012
◦ No supporting documentation in many cases to
support that the recipient was unable to self
medicate
◦ Handout: Med Pass – Medication Self
Administration of Medications

16. Other TidbitsOther Tidbits
OIG will make increases or decreases
based on items found on the assessments
included in the review
EMR facilities do not have to print
documentation for reviewers but they
must be given individual access
MDS Signatures: Lack of signature may
impact payment on future reviews.
Exit calls: Have been delayed to allow for
software update.

17. Q&AQ&A