Top 5 Nursing Documentation Misses Impacting QMs and How to Avoid Them

LTC Clarified: Weekly News, Insights & Connections

Written By:

Janine Lehman, RN, RAC-CT, CLNC

Director of Clinical Services

Proactive LTC Consulting

Nursing documentation is the backbone of the care provided to long term care residents and supports many of the critical components used to measure facility performance, including:

Survey outcomes
PDPM and Case Mix Reimbursement
The Five-Star Rating System
The Quality Reporting Program (QRP)
Quality Measures (QM) and publicly available information on Care Compare
Medical Review and Government Payor Audits

Errors in nursing documentation can have a profound impact on each of these areas, as well as contributing to potential facility litigation risk. Identifying areas of vulnerability for nursing documentation errors and/or omissions is very important--especially those influencing the QMs, as they can be a driver of all of the components identified above.

“Proactive has been a reliable partner in managing medical review and ADR audit activity. Their expertise in ADRs, appeals, and documentation strategy has improved our response timeliness and strengthened the quality of our submissions. The team is highly responsive, organized, and aligned with compliance expectations.”

Hector C. Lugo, MBA, CHC

Director - Corporate Compliance & Audits, Majestic Care

Ask Proactive!

Q: We are in our survey window and some staff are nervous about surveyors observing care and asking them questions during survey. Do you have any tips to share for interacting with surveyors?

Written By:

LeAnne Lee, RN, BSN, LNHA

Clinical Consultant

Proactive LTC Consulting

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Upcoming Training Events

JULY: Check out upcoming webinars in July!

Addressing Fall Root Causes with Targeted Interventions - Webinar

Falls are a frequent challenge in skilled nursing settings. This presentation focuses on moving beyond surface-level fall reviews to meaningful root cause analysis and effective resident-centered interventions. Presented by Liz Wheeler. Learn More

Engaging the IDT Troops in Fall Management - Webinar

This webinar will identify strategies for assigning IDT roles/duties for fall management. Presented by Janine Lehman. Learn More

Emergency Preparedness & Facility Wide Safety Drills - Webinar

This session will provide insight into the critical components of Emergency Preparedness that are scrutinized during the survey process. Presented by Janine Lehman. Learn More

Care Planning Strategies for Achieving Success - Webinar

Methods for developing and reviewing/revising the care plan for falls will be reviewed along with processes for promoting consistent implementation of fall management interventions. Presented by Janine Lehman. Learn More

New! Personnel Management: Disciplinary Processes, Termination, Managing Conflict & Retention - Webinar

Personnel management techniques will be discussed to prepare the nurse leader for these tasks with or without an official HR department. Presented by Donna Wharton. Learn More

New! The MDS in Court - How Does Yours Stand Up? - Webinar

Presented by Janine Lehman for Caring Communities

New! QAPI Tactics for Sustaining Positive Outcomes - Webinar

This presentation examines how an effective QAPI program can be used to reduce fall risk, prevent repeat falls, and improve resident outcomes through data-driven decision making. Presented by Liz Wheeler. Learn More

New! MDS & Reimbursement Impact - Webinar

Participants will explore the financial implications of assessment scheduling, Section GG accuracy, diagnosis coding, and clinical documentation. Presented by Sarah Becker. Learn More

Proactive provides expert interim MDS completion on a short or long-term basis. Rely on us for accurate and timely MDS coverage during staffing gaps.

“The Proactive team has been a God Send. Having the partnership with proactive for any emergency needs makes me feel more at ease with any future vacation coverages, or emergency fills”

Emmanuel Wilson, DHA, MPH, LNHA, QCP, CDP

Administrator, Ave Maria Home, Memphis, TN

Contact Proactive LTC CareConnect for same-day access to seasoned clinical experts providing guidance to stabilize situations, reduce risk and move forward with confidence.

Learn more about our team

Proactive’s nurse, MDS, therapist, and operations consultant team includes SNF experts with backgrounds as DON, Operations Director, Clinical Reimbursement Director, Clinical Trainer, Surveyor, and Compliance Officer. Contact us to learn more about support options.

Our Services

Nurse Consulting	Interim MDS	Mock Survey
Legal Nurse Consulting	MDS Consulting	Medical Review
QAPI	5-Star	Regulatory Support
PDPM and CMI Audits	Infection Prevention & Control	Reimbursement Consulting
Training	Compliance Programs	Home Health Consulting