This document provides guidance from an OIG stakeholder meeting on documentation requirements for MDS 3.0 assessments. It addresses requirements for sections C, D, G, I, and O. Documentation must be completed within specified timeframes and signed. Electronic records require policies for signatures. Diagnoses must be current and impact care. Restorative programs require goals, interventions and evaluations. Respiratory therapy requires orders, evaluations, and training of qualified staff. RN signatures and license numbers must match. Facilities may record exit conferences and request reconsideration extensions. Medical necessity reviews are occurring, including for permanent approvals.

1. 4/29/2014
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OIG Utilization Review
Documentation
requirements for the
MDS 3.0
OIG Stakeholder Meeting March 24th
Section C and D
Interviews
 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

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Section G
Handout: DADS Provider Letter:
Nursing facility management must determine howADL 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 ofADL flow sheets, electronic or paper,completed by Certified Nurse
Aides is acceptable supporting documentation forADL 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.
ADL 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.
 ElectronicADL (Caretracker,Accunurse,Point of
Care,Etc.) documentation needs an Electronic
Signature policy
 Must be able to determine who is documenting
on those forms
 Handout:TherapyADL documentation
crosswalk

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Section 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
Section O
Restorative
 Certified nurse aides meet the criteria for
training for Restorative care if trained inTexas. 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 documentedin care plan
 Must be a periodic evaluation of the effectiveness
by a licensed nurse (OIG suggestedmonthly)
 Does not require a physician order
 Does not have to be written by a therapist

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Section O
RespiratorTherapy
 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.
Section O
RespiratoryTherapy
 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.

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Section O
RespiratoryTherapy
 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
Can a LVN Conduct Respiratory
Training: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 mustbe developed and approved by a certified
respiratorytherapist,registered nurse,or physician trained to
provide respiratory therapy services.(The LVN may participate
in developing but cannot develop independently)
◦ Must demonstrate competencyin training other LVNs. This
includes system to check:
 LVN competency in providing respiratorytherapy,and;
 LVN competency in training other LVNSs
 Competencymust be conducted annually

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Z0500A 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
Extrapolation
 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.

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Conference Call/Audio
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
ReconsiderationTimelines:
 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.

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Medical 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
OtherTidbits
 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.

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Q&A