Changes in MDS 3.0 Section Q and Implications for Nursing Facilities

The implementation of the Nursing Facility (NF) Minimum Data Set (MDS) version 3.0 occurred on October 1, 2010. Revised section Q in the MDS 3.0, termed “Participation in Assessment and Goal Setting,” has been substantially changed and expanded, requiring an entirely different approach by nursing facility care providers in conducting the assessment. The new section imposes new requirements that will necessitate extensive collaboration between nursing homes, local contact agencies, and community-based long-term care providers for a small group of residents.

Overview of Prior MDS 2.0 Section Q

Through Section Q of MDS 2.0, CMS sought to improve the transition of individuals from nursing facilities to community living and to support individual choice. The stated goal of Section Q was to assist providers, upon a resident’s admission to a facility and on other periodic occasions, in helping a resident return to their community if possible.

Section Q of MDS 2.0 thus contained a number of assessment items that sought to further these goals. In Section Q, nursing facility staff conducting an assessment were asked if the resident had expressed a preference to return to the community and whether the resident had a support person who was positive toward discharge. However, assessors were not instructed to ask the resident these questions directly and could answer the MDS questions based on their own observations. The MDS 2.0 only required that nursing home staff ask the questions upon admission to a facility and annually thereafter. Furthermore, under MDS 2.0 an assessor’s findings were recorded in the MDS database but the nursing facility bore no obligation for follow-up action beyond traditional discharge planning requirements at 42 CFR 488.

Overview of MDS 3.0 Section Q

The new Section Q arose from legal requirements to ensure that all individuals have the opportunity to receive long-term services and supports in the least restrictive and most integrated setting. This opportunity is now law under the Americans with Disabilities Act and the U.S. Supreme Court decision in Olmstead v. L.C. and E.W.[1]MDS 3.0 seeks to provide a more patient-centered assessment theoretically increasing the referral of, and transition of individuals to community living. Thus, the new Section Q now requires additional efforts by nursing facility care providers in conducting the assessment and generating and processing appropriate referrals.

A new item in Section Q requires the assessor to directly ask the resident if they are “interested in speaking with someone about the possibility of returning to the community.” If the resident responds “Yes”, then the facility must initiate care planning and must refer the resident to a state-designated local contact agency that will inform them of what care options and supports are available. Nursing home staff is additionally expected to engage the resident in their discharge and transition plan and collaboratively work to arrange for all the necessary community-based long-term care services.

Also in contrast to MDS 2.0, the MDS 3.0 Section Q includes a more extensive series of questions for assessment and investigation for care planning. Assessments are also now required to be more frequent. Under MDS 3.0, Section Q must be completed at admission, annually, quarterly, and upon a significant change in the resident’s status.

Implications of Section Q for Nursing Facilities

The new requirements of MDS 3.0 Section Q will require additional time resources of nursing facilities and coordination with outside agencies. Under the previous MDS, Section Q required little interaction with the resident, little of the resident’s participation in the assessment, and no mandatory referrals or coordination with other agencies. The new MDS 3.0 requires an assessor to ask residents a number of direct questions. Depending on the answers to those questions, the nursing home may be required to initiate a referral to a “Local Contact Agency” (LCA). In Virginia, the Department of Medical Assistance Services (DMAS) has designated the Area Agencies on Aging to serve as Local Contact Agencies for Section Q referrals. A spreadsheet of these agencies is available at: http://www.vda.virginia.gov/localcontactagency.asp.

After initiating a referral, the nursing home is then expected to coordinate and cooperate with outside agencies and the resident in forming a discharge and transition plan. The following list explains the responsibilities of nursing facilities:

• If directed by resident responses to MDS 3.0 Section Q, the nursing facility must contact a LCA within eight business days using the MDS 3.0 Section Q Referral Facsimile Transmittal Notification and Tracking form (see attached)
• The nursing facility must confirm that the individual receives information on community services as provided by the LCA.
• After the individual chooses a “Transition Coordination Provider” (TCP), the nursing facility must inform the LCA of the choice by using the MDS 3.0 Section Q Referral Facsimile Transmittal Notification and Tracking form.
• The nursing facility must coordinate and assist the TCP in facilitating a transition to the community if appropriate. This could include arranging a face-to-face meeting between the individual or individual’s preferred contact, the TCP, and the nursing facility.
• The nursing facility must document all actions and the decisions of any individuals regarding their desire to transition to the community, participate in available training on community living options counseling, and adhere to HIPAA requirements.

A Statement of Understanding developed by DMAS further delineates the roles and responsibilities of the various parties involved when generating and processing MDS 3.0 Section Q referrals. The SOU also includes a helpful workflow chart visualizing the process for referrals and follow-up. A copy of the SOU is attached.

Enforcement of Section Q Responsibilities

CMS has clarified that the long term care survey process does not include a discrete task for Section Q follow-up or discharge planning. However, CMS has also noted that the local Ombudsman can be asked about Section Q results and required referrals. Any issues or findings that demonstrate residents are not being properly referred would be further investigated, and a survey deficiency levied when appropriate. Thus, failure to follow Section Q protocols, while not a separate survey item, could expose a facility to findings of deficiencies.

Conclusion

The new Section Q requires prompt attention by nursing facilities in order to comply with the October 1, 2010 implementation date. If our firm can be of assistance to you in interpreting the requirements of MDS 3.0 Section Q or with other long term care facility legal needs, please let Peter Mellette or Harrison Gibbs know.

[1] In Olmstead, the Supreme Court indicated that a state may be able to fulfill its ADA obligations by demonstrating that it has a comprehensive, effectively working plan for placing qualified persons with disabilities in the most integrated setting appropriate. 527 U.S. 581 (1999)