andy3k 3,374 Views
Joined Sep 21, '09.
Posts: 124 (19% Liked)
A late assessment bears financial penalizations in my state. I would guess there could be a compliance deficiency issued too.
As for doing a missed assessment between two already done, I don't know how to answer that. I wouldn't want to put in an ARD between two already done as it is fraudulent.
I would be careful when marking not federally required for item A0410. This is about privacy, authority of entities to collect MDS information and should be programmed into your software and not varied from assessment to assessment. It is about how your beds are certified, not actually who receives the information. (From RAI page A-8, A-9)
1= Bed is not Medicare or Medicaid certified and state has no authority to collect information
2= Bed is not not Medicare or Medicaid certified, but state has authority to collect information
3= The MDS record is for a resident on a Medicare and/or Medicaid-certified unit
Our facility marks 3 with every assessment, then makes a seperate file before shipping to store our insurance MDS's in, it then populates our software with the correct RUGs for billing information
That's a beautiful story. I'll share one of my own, about a little thing that ended up meaning a lot to one woman.
My patient *was* dying. A long, drawn out decline and a little over five months spent in my department on what was her final admission of many.
When she first came to us, she was mostly bed-bound, but could get up to a commode with minimal assist, all the with the ever-present oxygen mask (mere nasal prongs weren't enough). Eventually, getting up became too much, and after a couple of months she no longer left her bed at all.
The prospect of a shower was too much for her to bear. Even when she was getting up, even with our cushy shower chair and portable oxygen, that much movement, humidity, and stress would've been too much for her to handle. She knew it and so did we.
She got bed baths, of course. And new sheets. She never said so, but I knew it bothered her that she hadn't been able to have more than that.
I wasn't often her primary nurse, but this day I was. It was a rare uneventful shift, likely a weekend. I brought piles of linens -- extra flannels, soaker pads -- shampoo and two full basins and pitchers of warm water.
I soaked the heck out of that bed, washing her hair and giving her the wettest bed bath I have ever done. Wrapped her in warm flannels, dried the bed and changed the sheets (while she was in it), lotioned her up, combed her hair, and tucked her in.
It isn't often I have time to do that, and I felt good about it afterward. The best part was her smile, as she told her husband (the lovely man who visited faithfully three times a day all those five months) how nice and relaxed and happy she felt after her bath.
So there's a little thing, something that was maybe little in theory but big for her. I still remember the smile on her face, through that plastic mask.
As much as nursing is about skills and knowledge, it's also about these little things. I'd love to hear more stories.
She called my name down the hallway. To me, at the other nurses' station. Why she did that, I don't know. I had a phone next to me. She's the unit secretary. Why doesn't she know my extension?
"You have a phone call. Johnson's brother. Wants to speak to his nurse"
I call back (now we are just raising our voices at each other, how foolish) "Transfer the call over here."
She calls back at me. "What's the number at your phone?"
Again I wonder- why don't you know the number? But I don't ask her aloud. I reply "6015" The phone next to my computer rings and I answer.
"Third floor, this is SarahLee, how can I help you?"
I hear a voice, sounding far away and yet right in my ear. "This is George, Elizabeth Johnson's brother. I was wondering if you could tell me how she is doing?"
I ask "Are you her health care proxy or power of attorney?"
"No, just her brother," the voice seems frail.
My HIPAA training kicks in. I search my brain and scan through the computer in front of me to see if this person is a contact. I don't see his name in the computer and the chart is at the other nurses' station. Then inspiration strikes me.
"I'm sorry, can you hold on for just a moment?" I ask. I press hold on the phone and walk down the hallway.
Knocking, I enter. "Elizabeth, your brother George is on the phone, wondering how you are doing. Can I give him some information?"
Elizabeth looks up and smiles. "Oh yes! I have been trying to call him! Please tell him anything that he wants!"
I go back to the station and the phone, press hold again and just get a dial tone. I lost him. I must have hung up on him, poor man. Another victim of my sad phone skills. Sighing, I go back down the hallway.
"Elizabeth, do you have his phone number? I'm sorry but I think I lost him."
She searches her brain as she is lying there on her bed: "Oh yes, it's 478, no 784, no...oh dear, I'm always forgetting it..."
Suddenly, the overhead page is heard, "SarahLee, phone call front desk. SarahLee, phone call front desk."
Thankful, I say "Never mind Elizabeth, that's probably him"
I go straight to the unit secretary this time. No more fancy phone maneuvers for me. She tells me how to use her phone, I sit down and I answer it. Quick apology for hanging up on him "I never could run these phones."
"It's ok," he laughs nervously. Then, without skipping a beat, like he was diving into a pool before he lost his nerve, he asks: "Sarah, is my sister going to die?"
Stunned at the suddenness of such a request, I search through my brain about the woman I just left in the room. Respirations even, non labored, alert, talking, laughing, getting up as needed on her own, very limited pain. Speaking cautiously, I reply "No...I wouldn't say that she is going to die. I mean, of course, I can't see the future. She's going to need some time to recover, certainly, but no, right now she's not dying."
Suddenly there was a silence on the other end. No talking, just deep breathing heard, in and out, in and out. I thought I had hung up on him again. Finally I say "Um..sir..are.. are you still there?"
Deep breathing and then, a tearful voice, full of anguish, speaking in a rush now, "I got home and had a message from our other sister, they said she was doing terrible, not well at all, that she was dying...I tried to call her room several times and I couldn't get through...so I finally thought I should try the nurse...so I've been trying to get through at the desk...." Then I heard the sound of him blowing his nose.
And there it was. That moment that comes every now and again, where I am going along doing a normal day's work and then suddenly I feel like an observer of my own life. Like I am someone who is looking through a glass at all these different people walking around and suddenly I see two people who have never met before meet at an intersection.
Without warning, his day's crisis had smacked headlong into my day's routine. What was he thinking when I put him on hold to ask my patient's permission to talk to him and then subsequently hung up on him?
He had thought his sister was dying.
Did he think I had to find someone else to break the news to him? Did he think that he would never hear his sister's voice again? Did he think that the nurse didn't want to talk to him?
When I picked up the phone, I thought that he was going to ask some general questions like "How is she doing, when can she go home, can I come and see her?"
But his question was more serious.
His question was his biggest fear. He didn't even know if she was dead, dying or alive.
Our phone conversation continued and we talked a little more about her health. His tears and fears subsided. I could tell that relief was spreading right through him. I could almost see his smile over that phone line, if such a thing is even possible to say. At the end of our conversation (with the help of the unit secretary) I transferred his call to her room where he and his sister had a good conversation.
She called me into the room later and gave me a big hug. "Thank you so much," she said. "He was so afraid" and we laughed together, as two people who knew a private joke.
But the rest of that shift, I felt what must be one of the best feelings in the world. I felt like smiling, laughing, running down the halls like a fool.
Because my patient wasn't dying. She was very much alive.
I had put one person's mind at ease. And I got a hug and a thank you from another.
What more could I ask for? So don't ever underestimate the value of the little moments in nursing, like a phone call. Small routine moments in our patient care may turn out to be one of the biggest moments in our patients' and their families' lives.
And we get to be part of it. How amazing!
What little moments have you been a part of?
3/20 – Entry (valid)
3/26 – 5-Day (valid)
3/26 – DC tracking (invalid)
3/28 – Reentry tracking (invalid)
4/4 – 5-Day, should be Readm/Return (invalid)
4/14 – 14-Day (invalid)
4/28 – 30-day (invalid)
4/29 – DC (valid)
You would have to invalidate five invalid MDS. However, you cannot go back in time and create the missed assessments using the ARD window. See Clarification #8, pp 8-9
The facility will have to take the loss and bill as:
3/20 – 3/25 CA1
3/26 – 3/27 (observation status = LOA, no pay)
3/28 – 4/2 CA1
4/3 – 4/28 No PPS assm’ts done, bill default rate only**
**If you did an OBRA Admission MDS with ARD that fell within the window of the missed 14-day PPS, you may be able to bill the actual RUG category for days 15-30 (in your case 4/3 – 4/18). See RAI, 6-55 if you qualify.
What you do with the date changes in your system is but a facility practice. It has nothing to do with MDS's Entry Date.
Entry Date defined, Appendix A-6...
The initial date of admission/entry to the nursing home, or the date on which the resident most recently re-entered the nursing home after being discharged (whether or not the return was anticipated).
just start this position, and the one who is training me doesn't know the schedule clearly...so sad
here is my question:
how do we set new admission ARD for private pay resident? I know we have to complete the MDS before Day 14, but the thing is sometime day 14 fall over the weekend.
how do we set new admission ARD for MedA resident?
The best care plans are resident centered....based on the needs of a particular resident. These aren't usually found in a book or a computer.
I was still a student and doing a rotation on L & D. I was spending the morning in theatre watching Caesarians. That day we happened to have a rather infamous (d/t drugs, scandal etc) ex-football star's partner giving birth. He was present, of course. Was rather surreal watching their baby being born, I watched his face, he was clearly awestruck at the birth of his first child. He was quite humble and friendly, to our surprise, joking around with staff. It was his partner who was a bit strange. Afterwards on the ward, he even asked another student and I to help him give his baby it's first bath! His whole family was there watching, we chatted to them, they were proud and friendly also. The magazine spreads that followed claimed he'd "turned his life around" etc etc now that he had a child. I had hoped so. Unfortunately it wasn't long until more drug scandals occured. I was so sad, he had been so excited to be a father. Just shows the terrible hold a drug addiction can have over someone
I was taking care of the Archbishop after CABG. He was giving me a hard time taking his meds. Getting a bit impatient I said "See just like you. You do it everyday . Open your mouth,"( then I popped his pills in ) saying .''There ya go. Body of Christ ''.
OPS!!! I promptly bolted out of the room when I realized what I'd blurted out .He sat there mouth gaping like I was the divil incarnate. I still cringe thinking about it.
When I first got out of nursing school 15 years ago I received my first job at a nursing home. I was called all sorts of names by my preceptor. Incompetent, stupid. I'd leave the orientation crying..
I stuck it out for a year. Even after orientation the other seasoned nurses were just MEAN. Over worked probably played into the equation. But perhaps there wouldn't be such a revolving door if nurses were NICER. I just always felt stupid. If I asked for help, a nurse would tell me I should know it already and just curse me out and I got to the point I didn't want to ask for any help...Heck, I was scared to say good morning to most of my coworkers.
One Christmas I came into the nursing home to find out the 5 other nurses were "sick". (there were 3 floors, 2 nurses to a floor). 50 residents EACH floor. I cried the whole shift. I remember calling MY DON, and she was telling me that agency nurses were coming. They didn't show up until an hour before my shift ended.
I left there and for the past 14 years-I got a nice cushy job at a methadone clinic. This pretty much means my skills got rusty while I dished out methadone from 6a-3p. I had great hours,(great for me since I am a morning person)great pay, actually got to sit down and use the bathroom when I wanted, and was pretty complacent. What I should have been doing is done some floor nursing on the weekends, and been prepared for when funding was cut to the clinic.
And then the clinic was closed. 15 yr Lpn with basically no skills. SCARY. It was either pay my bills or go out in the street. I had to relearn. I couldn't be scared even though I was. I wondered if I would feel stupid and incompetent like last time.
Well, I applied to a different nursing home and my experience was VERY different than last time. I let her know I had worked methadone and was VERY rusty. At first I thought she'd give me a hard time, especially being an LPN for so long and yet being so rusty. I had my tissues ready for when I would cry afterwards. Didn't need them. Actually she WAS SO Patient. SO NICE.
I fell in love with bedside nursing again.
All the skills I was afraid of? I felt like a VERY different nurse the 2nd time around. Soon I was running circles around the other nurses.
Well, I am now doing home health nursing dealing with primarily vent dependent patients every other wekend(if you had told me I'd be doing this 2 years ago I wouldn't have believed it!) and doing my nursing home gig M-F. LOVE IT! LOVE IT!
What a difference a kind nurse preceptor makes! Sometimes the administrators at the nursing home get on my nerves..but this time i get along with my nursing coworkers, unlike last time. That makes all the difference to me.
Well, at the home health nursing agency I also work at- they sent me to a new assignment a few months ago. Patient had round the clock nursing and also a round the clock nurses aide.
While I was working I found out the aide that was working with me, the aide I was delegating duties to - was an RN.
I wanted to know why was she working as an aide (under me!) when she could be working as an RN??!!
She told me she graduated a year ago, and felt incompetent. Cried every time she went to the hospital because other nurses would yell at her.
She said she decided to work as an aide to feel more comfortable. But still, she felt horrible. Her self confidence was torn down.
I saw myself in her. And i realized this was one less nurse on the work schedule so that the rest of us really have to bust our ****!
So I let her observe me doing things, talking to her about why I did so and so,etc. without tearing her down.
She now left work as an aide and is working as an RN. I hope she remembers me...she may be my boss one day!
So we dont need to do anything correct? Do we need to do another assessment to correct?
I'm beginning to wonder though if I made a mistake. Post after post on here I read about the "horrors" of LTC and how much many of the nurses on here hate it. LTC is all I have ever done and have always enjoyed it. I have never had the desire to work in a clinic. Every clinic nurse I know hates the clinic lol!
I don't know...I feel like working with the elderly is a calling. I feel so rewarded when I make a difference in just one person's day by taking the time to speak and acknowledge they exist and having someone tell me they look forward to my shifts and miss me when I'm off. Just little things like that you know?
40 - Certification and Recertification by Physicians for Extended Care Services
http://www.cms.gov/Regulations-and-G...s/ge101c04.pdf see the guideline, from p12
There is no requirement that a specific procedure or specific forms be used, as long as the approach adopted by the facility permits a verification to be made that the certification and recertification requirements are in fact met. Certification and recertification statements may be entered on or included in forms, NOTEs, or other records a physician normally signs in caring for a patient, or a separate form may be used. Except as otherwise specified, each certification and recertification statement is to be separately signed by a physician.
I really think that delegation of duties and who actually does what varies from building to building, company to company.
Where I work, I do 90% of the MDS and usually all the CAAs. Everyone is always busy. Staffing is always less than ideal. In all my years of MDS, just this past year I started going entirely case mix. With everything going on with the changes, it wasn't that hard to give up PPS. Doing case mix has made me see things in a different light though. Our charts have stickers for MCR (we use them for mgd care as well). The floor nurses are in tune to look for those and usually chart fairly well. Other areas like the rehab depart, SW notes etc are good sources for me when doing PPS. For case mix we make out lists ahead of schedule as to what date which resident is having an assessment done, but honestly with the Mcr/Mcd reimbursment changes it's all anyone can do to do the minimum. We had layoffs, pay cuts, layoffs again and again. (I was actually part of the last tier of layoffs.) Then of course something comes up and an assessment has to be added and another postponed.
For case mix, I had to do quarterly nursing assessments on each of the residents I was working on which consisted of Brayden scale, fall risk, transfers, bowel and bladder, pain, all psychotropics for consent for present dose, aims if needed, smoking if needed as well and restraints, but we didn't have any in the building. I gleaned the chart for changes etc, interviewed the resident and usually because of time constraints, if anyone's part wasn't done, i would do it. More times than not I was doing it. I didn't mind if it was something that I came across anyway or could find easily, but I hated having to interview the resident for mood. After all my interviews and data input (or before) I had to write a lengthy nurses note that covered each of the items that there was no documentation for, such as behaviors, seat cushions and pressure reducing mattresses, the results of the restorative nursing, any changes in adls or any temporary condition that might cause a temporary change and not a significant one.
Very often, unfortunately, I would come across something that was missed. Perhaps something as simple as MD needing to be notified of recent blood sugars and current insulin or oral hypoglycemic doses. It might be something I saw during my interview that needed further assessing and follow up or even sometimes hospitalization. Labs were not put in the chart regularly,or were kept in a different place until filed and all x-rays, MRIs, CT Scans, I called the hospital for a copy to put on the chart. The same with hospital discharges or notes from an ER visit or dialysis notes. It could even be an order written that no one took off. I took it upon myself to pitch in with these things because I am the patient advocate. I am supposed to be his champion. The nurses love the patients and follow up as best they can, but we seem to be more interested in filling in a square, signing off on some lame "inservice sheet" that someone just made up because of something that happened or going to more and more meetings to see that we are doing our job and catching things. And most facilities I've worked at the residents have so many medications. They are coming in sicker with poor prognoses and nutritional intake just waiting to become pressure ulcer candidates. Or they may be bariatric patients with personality disorders and demanding demeanors. whew! Well.... I guess we all know we are in a mess and in this together.
I enjoy working. I'll do almost anything as long as it's ethical and in my scope of practice and I feel it's in the best interest of the resident. But like everyone else, my time is limited. I have deadlines. Who do I perfer to get mad at me? Why do I have to ask this question? If I'm salaried and work way way over 40 hrs, I put off my own appts., MD, dentist. If I'm on the clock, I can't get overtime. We need clones. I read where one of the CEOs (won't mention any names) in his quarterly report to the board and stock holders "we're cutting back all we can and nurses won't work for pauper pay you know" No, but now we get the privledge of doing the work of two people.
By the way Cape Cod Mermaid, what is your position now? Are you DON? Katoline
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