CAA Summaries

[ibtootie]

When I was trained in MDS 2.0 our SNF was a tiny, hospital based facility and the documentation system was the same system as the Acute Care's documentation. Suffice it to say that it didn't work well due to the SNF residents needs not being the same as the Acute Care patients needs. I was trained to do RAP Summaries on the patients and we had to write our own care plans out, as the care plans in the computer system were for acute care. The RAP summaries could take up to an extra 45 minutes to an hour to complete on each resident. Since then, our census has doubled and we have re-vamped our system to incorporate SNF patients and develop a beautiful care plan unique to the resident with a few clicks of the mouse. Now, I'm asking myself if I'm wasting time composing those long, drawn out CAA summaries, when it is already in the Care Plan and documentation to begin with. Can someone advise me on the necessity of doing CAA summaries and how to do them quicker?

[Talino]

written documentation of the caa findings and decision-making process may appear anywhere in a resident's record; for example, in discipline-specific flow sheets, progress notes, the care plan summary notes, a caa summary narrative, etc.

use the "location and date of caa documentation" column on the caa summary (section v of the mds 3.0) to note where the caa information and decision-making documentation can be found in the resident's record. also indicate in the column "care planning decision - addressed in care plan" whether the triggered care area is addressed in the care plan.

rai p4-7

if info required is addressed in the care plan, simply write "see cp date 00/00/2011". if the info is also addressed in a dietitian's pn or a rehab therapist's eval and treatment plan, point to that location.

[LNFMDS110982]

I have a question regarding MDS Care Plans for all you MDS Nurses - Does a resident still require a care plan if they are discharged before the 7 day window following the initial 14 day admission assessment? I just began working at a new facility that has many residents on Med-A that make it to the 14 day/admission PPS, but are discharged a few days afterward. This often does not give us time to meet and have an interdisciplinary team meeting to formulate a care plan for the resident. I know the Care Plan is not technically due until 7 days after the Admission Assessment is signed as complete. But for us, many times the resident is gone before we have a chance to get a pare plan formulated. I just want to make sure we remain in compliance with CMS. Any thoughts would help. Thanks!

[lifesaver252]

if you guys have an admission care plan, (which is probably very basic, ours is basically checkboxes the nurse can fill out when she admits a patient), it should cover you if the resident is discharged before the seven days after completeing the admission assessment.