MDS SYSTEM SCORECARD

Title Page

Facility
Date
Prepared by
Location

Instructions: Review systems below and score components based on findings during a Routine Visit. Calculate score for each system and for overall score every visit.
For any area that is 80 points or less, a SIPOC will be required. The SIPOC must be submitted by the facility to the Regional QA Nurse within 5 days from receiving the report. Timeframes for correction should range between 30-45 days or even less, but never to exceed 45 days. Upon week 8 following the initial Scorecard and subsequent revisits, the Regional QA Nurse will schedule a date(s) with the facility to complete a new Scorecard. Depending on the extent of the needs of the facility and the Regional QA Nurse schedule, the Scorecard may be completed within 1-3 days or with two Regional QA Nurses.
Critical Flag - A facility may show overall substantial in an area demonstrating that they provided the needed documentation and follow up with the exception of possibly one area but that a significant event with patient potential for harm or patient harm occurred as a result of one of the criteria not being met. In the event that this should occur, the facility will note that they will receive the credited points based on what documented items are present for the system, but a Critical Flag will be issued to reflect that a critical event occurred as a result of the facility failing to follow their policy and procedure or as a result of patient circumstances rendering the facility vulnerable to receive a harm level citation or potential for harm level citation.
Please be sure to complete environmental & care rounds each time you are in the facility.
Please be sure to arrange for medication administration observation by the pharmacy or from within.

MDS - OBRA/Medicare

1. Admission MDS completed timely and accurate.
2. Annual MDS completed timely and accurate
3. Quarterly MDS completed timely and accurate.
4. Significant Change In Condition MDS completed timely and accurate.
5. Signficant Correction completed (prior to comprehensive MDS)
6. Significant Correction completed (prior to quarterly MDS)

MDS - Medicare/Discharge

1. 5 Day MDS completed timely and accurate.
2. Interim Payment Assessment Completed appropriately.
3.Discharge Entry completed as needed.
4. Discharge Assessment with Return Not Anticipated completed timely.
5. Discharge Assessment with Return Anticipated completed timely.
6. Death in the Facility Completed.

CARE PLANNING

1. 48 hour baseline care plan completed timely.
2. Comprehensive care plan completed timely within 21 days from admission.
3. Care Plans are reviewed and revised at minimum quarterly and as needed.
4. CAAs are completed upon admission, quarterly, and with significant change
5. Care Plans are individualized to address the residents individual needs.
6. Care Plans are reviewed with the resident or resident representative with changes.

ANCILLARY DOCUMENTATION/ASSESSMENTS

1. PHQ-9 Assessment in place.
2. GG Assessment in place and accurate
3. Ancillary UDAs are in place on admission, quarterly, and with significant change to support the MDS.
4. ADL documentation current - POC at 80% or greater
5. Skilled Documentation/Charting in place consistently.
6. Validation Reports Reviewed with no errors or error corrected

MEETINGS

1. Weekly Utilization Review is being conducted - Minutes
2. Weekly Risk Meeting is being conducted - Minutes
3. Care Conferences are in place - Minutes
4. Morning Meeting is being held to discuss residents with potential for increased CMI or score.

QUALITY MEASURES

1. Quality Measure Review at minimum monthly
2. Quality Points Review - What are the current points?
3. CMI/Quarter
4. Quality Add-On Points

TRIPLE CHECK - BILLING

1. Physician orders signed before end of service.
2. Physician certification and recertification forms signed timely and all areas are complete.
3. Therapy Diagnosis Codes are in place and reviewed
4. Triple Check call is conducted as scheduled and all areas of the claim are reviewed.
5. NTA Diagnosis are present.
6. Administrator, BOM,and MDS participate in the Triple Check Meeting.
7. POC Treatment Plans for Therapy are signed and dated.