DNS/DON question

[pixie120]

I am wondering if any other DNS/DON's have run across this before. SO....I have MDS experience, a lot, very skilled at it actually. It helped me get the DON position. In a new facility, talking the usual MDS stuff in the AM meetings, PPS meeting and particularly Medicare meeting/UR meeting. Rehab manager (SLP) doesn't seem to understand half of what I say. I drive the MDS, I never let it drive us. It has been about a month now, SLP STILL inflexible, resistant, un-educated and NOW with "new" behaviors, including running to MY administrator, about ME. SHe works for a sister company, facility owned by same parent company (would think that would make things easier? Nope.). Administrator good, supportive, no MDS knowledge but gets that there is to be a meeting everyday and we are to talk about minutes, although he really didn't get that until I walked him thru it last week,and showed him the ARD form. SO....whole team has little to no knowledge of MDS, how to drive it, capture higher rates etc etc etc.

After we had the little impromtu meeting prompted by SLP running to MY administrator, about ME...Adminstrator comes to me and says these fateful words "You know......you don't want to be perceived as.......being part of......having behaviors.................. causing her to have her behaviors..........should have been able to have effective meeting without my interventions.............things are in flux/changing........set her off...............".

Ok here is my dilemma. I am pretty much done with all of this, over it. Have been here before, done that. JUST left a difficult building where NO ONE could cooperate and focus on the task at hand, or take care of the residents.

This whole month has been a huge transition for this building, NOW,of course, all of this is MY fault (well of course it is, I am the new team member, hired to get some stuff fixed.... lol). I really, really really am tired of having fingers pointed at me as I HAVE A BEHAVIOR when (as I told the administrator):

1. this is business, not personal

2. this is about minutes, timely, from slp, without having to chase her all around the building.

3 should be able to change the ARD date without a congressional hearing, AND the MDS nurse's MUST know about the changes (not a secret)

4. HOW MANY TIMES DO I HAVE TO SAY THE WORD MINUTES?

5. It may be that I will have to instruct the MDS nurses to submit without minutes and do amendments, as this SLP apparently cannot get minutes timely, and she certainly cannot figure out how to get minutes for all residents that she is treating, including the Medicare B.'s

Don't get me wrong, I get paid good money. I was hired for a specific job, (that is ALWAYS what they say BEFORE they hire you..afterwords????)

My question for DNS/DON: how would you handle this? WHat if you thought the MDS nurse's would get frustrated and quit and then?..... As we all know this affects the nursing budget, how far to push this?...... Regional's are fine, but distant, focused on pychoactive meds right now, aware that MDS is in flux, 3 RCM's doing MDS, with only one really knowing what is needed plus me.

Have another offer to work in another building, starting to re-look at that offer, is this bad? I think I can help this building get thru survey then....(we are in survey window now) probably October...I struggle though with loyalty issues, don't want to seem ungrateful for the great offer that is now my job, but not what I expected and under no circumstances am I going to allow this building to personally and professinally attack me with their bad behavior. Unacceptable and I have other offers and things that I would like to do. I JUST crawled out from under the bus, not willing to go back under there.

Please speak freely, looking for some tough love here.

[pixie120]

I still see this as fradulent knowing there is information out there.

You come across as very hard core, angry and unapproachable in your posts along with the statement that you have been thrown under the bus. (ok...I will give you that, I was venting, very frustrated but I don't get where you see that I am unapproachable....? angry? Frustrated by the lack of cooperation, after a difficult meeting with a difficult department head, doesn't make me unapproachable...where are you seeing that? Are you suggesting that I simply let sleeping dogs lie/lye? Not a great solution, and ruffling people's feathers when they stop dead in their tracks, in the middle of the road, is sometimes needed to get a stuck person unstuck.)

I suspect you are contributing a great deal to the situation at hand. You may want to get some objectivity. (How am I contributing to the situation, a great deal, when he/she has the minutes, won't/can't give them, and nursing needs them? What is the suggestion here? We ignore, submit inaccurate MDS...it was a question...)

Best wishes to you and your team.

NO fraud, no submissions. This was a question of what to do. I cannot see where I am being deemed hard core when we are required, as you indicate, by federal law to have accurate minutes, in a timely fashion so we don't default or send in inaccurate MDS. (Following the rules makes me hardcore?) )NOt giving her/him any slack is hardcore? Repeating for over a month, the same request, with no change is hardcore?

Not clear in your post what the suggestions are to GET the minutes.(the name of the threadis DNS/DON question). It's been fixed, by the higher up's in both our companies, and now nursing has minutes, and problem solved. And...I think I still have behaviors..... Maybe I should sit and do nothing? Cuz that is also a behavior, lol.

Just as a footnote, this all goes right back to the problems in LTC/SNF with the nursing teams. We cannot allow bad behavior, failure to perform, failure to collect data for the MDS to continue simply because someone or a whole bunch of someone's don't like it, or dont' like the way someone said it. IF we don't police and monitor ourselves, the state and feds will and we will not like it!!

Nurses need to mentor and bolster each other, not charge others with crimes that haven't even occurred or are likely to occur. I see that word fraud bandied about in LTC all the time and it's simply amazing to me that we threaten each other with this all the time. Because I asked a question on a message board, I am now committing or thinking of or advising or gonna make someone commit fraud? SO....we as nurses, cannot have an open dialogue cuz to think it is to do it, then there is the crime? A retorical question at best. Thanks for listening and thanks for the best wishes, I appreciate it!

[pixie120]

Sometimes it is not what you say, but how you say it. It can keep people from listening. Love the saying "Say what you mean but don't say it mean". (Agreed)

Anyways - I think I would be tempted to let a couple default. I would put it in writing every morning before stand up what I need and when I need it by. The day prior to default I would nicely announce in stand up that XYZ will be in default tomorrow if minutes are not obtained. I would also submit this in writing to the ED at that time.

It won't take long and someone will be taking this seriously.

(Happened, the higher ups got it all nicely fixed, lol).

Yep, that word default is a great word, and we have everything in writing now. It was a very large hill, but we climbed it, and can see daylight now. Admin was quite interested in the entire process and took it took her boss.

[caliotter3]

Not a DNS, but read your entire post and you say you have other offers. Do not know that this is worth the stress. Look at your other offers.

[fulzgold]

I got lucky at my facility. The Rehab was an SLP with a head for business. I showed him the case mix index and explained how the nursing care, and therapy tx effects RUGS. I gave him the list of rugs with $ amounts and a list of requirements for achieving the same. He loved it. Pretty soon he was asking me for a list of residents and current rugs. I gave him the rules on date setting for the different assessment types and started letting him set the dates. He always worked with me and understood if I lost a higher nursing RUG by using a therapy date that took skilled nursing out of the look back period, then he would have to use minutes for the date I needed. The date setting was a mutual effort. Our case mix has been really good. Too good, now corporate sent him to another sister facility to help them out. He says he misses our team work. The team at his new facility is resistant and tempermental. Nursing doesn't talk to therapy, therapy doesnt see the need to talk to nursing, MDS C. refuses to consider team input on the MDS schedule and sets it in cement. They all know the rules, they just don't see the end results of pooling talent. Shame. Our new rehab is only a COTA with a BA in something else. she's real nice, I hope it works out. I'll have to train her too. Sheesh!!!

[pixie120]

I got lucky at my facility. The Rehab was an SLP with a head for business. I showed him the case mix index and explained how the nursing care, and therapy tx effects RUGS. I gave him the list of rugs with $ amounts and a list of requirements for achieving the same. He loved it. Pretty soon he was asking me for a list of residents and current rugs. I gave him the rules on date setting for the different assessment types and started letting him set the dates. He always worked with me and understood if I lost a higher nursing RUG by using a therapy date that took skilled nursing out of the look back period, then he would have to use minutes for the date I needed. The date setting was a mutual effort. Our case mix has been really good. Too good, now corporate sent him to another sister facility to help them out. He says he misses our team work. The team at his new facility is resistant and tempermental. Nursing doesn't talk to therapy, therapy doesnt see the need to talk to nursing, MDS C. refuses to consider team input on the MDS schedule and sets it in cement. They all know the rules, they just don't see the end results of pooling talent. Shame. Our new rehab is only a COTA with a BA in something else. she's real nice, I hope it works out. I'll have to train her too. Sheesh!!!

Yes, you were very lucky. I do agree that often it IS the nursing team that is resistive, set in stone, won't work with therapy but I worked for a long time as the Restorative nurse and went to a lot of MDS and therapy trainings, restorative etc (worked fora very good company that provided outstanding training in all areas, not the big K or S). I also have had the extreme pleasure of bringing therapy to on site at assisted living, and in the last year, that has just blown up, seems all the AL's are now or going to get on-site therapies (they typically bill Medicare B, 20 visit limits per PT, OTand SLP). That company is my preference to work with, cuz THEY drive the MDS and in the 5 years that I worked with them, they NEVER missed a higher rug and NEVER fought with the nurses even the difficult ones, cuz that company was new, hungry and JUST a rehab company not part of any "parent" snf's etc.

I am very pleased that this issue has been resolved, and it just seems like SUCH a shame that more rehab companies and managers DON"T get how very,very important these MDS things are. In this rehab manager's defense, she just didn't really understand the MDS, neither did her team because another situation that came up is the PT believed that she was "holding" people on Medicare A "somewhat fraudulently" (her words) because she believed that the person had no skilled nursing needs.

We helped her understand that nursing always skills and supports the MDS and therapy and that SLP can't be in by self (so plus nursing), PT alone, ok, OT alone ok, and Nursing alone ok but for really only 5 situations, without therapies, which are very time limited(potential to decline, new med, stage 3 ulcer, new tube feed etc).

SHe was very pleased to hear that nursing supports her being in as the PT, and that really is building a bridge of understanding between nursing and therapy, which, as you and many others know, historically have NOT gotten along very well in SNF's, for a variety of reasons.

As the leader of that team, I always mentor the nurses to premed prior to therapy, chart about progress and do the very important charting that supports the MDS, the therapy department, justifies Med A usage and improves patient outcomes (the whole reason we do anything that we do). It used to be so segmented, and nurses (I certainly didn't know anythying about Med A or charting or therapies as a new grad, I learned much of what I know from two very, very excellent therapists, one PT, and the other an OT, that understood the relationship and how to drive the MDS for better patient outcomes.

At least with a newbie, you can mentor/educate her/him to what the expectations are and start that ever important bridge between nursing andtherapy

[pixie120]

Not a DNS, but read your entire post and you say you have other offers. Do not know that this is worth the stress. Look at your other offers.

Yes, thanks for the post.... I am going to continue looking at these other offers. I am not 100% sure that this place is a good fit for me, or for where I want to be in the next 5 years. So many of the day to day issues are so easily solved, and so dramatically UNSOLVED that it really makes me question if I should stay or not. There really, really are facilities (I just came from one) in which the staff have been unsupervised SO long, they are just TOO resistive to changes that need to be made in order to get good patient outcomes. I see this in the managment teams as well. In this area alone, there are 8 vacant DNS/DON positions, all filled by "long-term" interims, and no one interviewing to take the permanent position. If one takes a job at a one star building, in 3-6 months, the problems of that building are now your's, and you are at risk to lose your job as is your team. It's really not worth it. The 5 star buildings only want DNS's from the hospital (new trend here) or with at least 3 years experience as a DNS in LTC, BSN minumum (I think that answers the other thread questions why an RN could get hired as a DNS in LTC, without LTC experience, cuz the corporation are looking for the acuity experience.)

Other DNS's please jump in here, it just seems to me that there are SO many coporations and facilities that let their buildings fall into dissaray, fire every person with a pulse and then "start" over with the new and better teams, it's such a roller coaster, why can't we get these places to stand behind us, do the right thing, give us budgets that allow enough aides per patient, and enough nurses to take care of the higher acuity folks, rather than tying our hands behinds our backs? It's really sad, it burns out all the staff, and it makes me want to go back to the hospital.

[pixie120]

Like Nascar Nurse said, document, document, document your requests for minutes. I'd let the MDSs go into default, too (I used to do MDS). Once the company starts losing money, they will have to look at why, and if you've documented that you've asked for minutes and can't get them from the rehab coordinator, then you've covered your butt. Be sure to go to your administrator first, I think, and explain exactly what you are expecting and what steps you are taking so that you have back up and the rehab coordinator can't twist your words/behaviors.

Thanks very much, great advice. You are so right, I did document, and I asked for minutes in every meeting as did the MDS nurses,and then we asked,and asked. Higher ups got it all straightened out,and we are now full speed ahead. So glad we didn't really have to default. Administrator was very,very pro-active on this one. Think the team is now going to be really great!

[pixie120]

If it is as you say, I would say get out. It will all come back to bite you.

I find it hard to comprehend that there are so many without an understanding of MDS besides you. Are they all newbies?

It seems that they are part of a coroporation? How can this be the case when the new changes are coming down the pike in less than 30 days.

Maybe you should just stay with an MDS job.

Oh, if my DON told me as an MDS nurse to sign and submit an MDS that I knew was inaccurate. I would flat out refuse even with threat of firing. The defense of my DON told me to wouldn't fly with any board of nursing or CMS audit or legal actions. It's wrong and you should know that as an experienced MDS nurse.

If you think that is what you need to do, I'd say - you sign and submit it.

Many,many people in LTC/SNF don't understand the MDS. Not newbies, but new to RN management, new team being formed, lots of reason's why. It takes a lot of knowledge and skill to figure out the MDS, especially since 3.-0. I know two 2.0 MDS specialists that seriously could not convert to 3.0 and went back to floor nursing cuz it's just that different, and now with new changes coming up, I see another wave of panic coming. The thing about MDS's is, you have to read the manual, often if not daily. ANd you have to get good solid advice from the state RAI's. Many therapies don't understand MDS (and why would they, they haven't ever nor wouldthey ever be expected to fill out an MDS, but most companies have great programs to set the dates, print out minutes etc). Are you an MDS nurse? a DON/DNS? Would you ever be either? It behooves all nurses to have some working knowlege of MDS, even if just how to chart to support the MDS.

[katoline]

Pixie, you are smart and you are passionate. tread lightly, do the MDS nurses report directly to you? or do they have a corporate, regional/district sometimes consultant like person? I've seen you from other posts under MDS and am an MDS nurse myself, have been an ADON, offered DON (wouldn't think about it ;-)

and no, i don't feel that submitting an assessment without all the information is fraudulent, submitting incorrect information knowingly is fraudulent. If an assessment will be late if you don't submit and you can't get the information you need from therapy, it doesn't change the assessment, only the reimbursment. If there is a regional/district whatever MDS person, he/she should get involved. Issues such as these are going to make a BIG BIG difference and you're right, it didn't take long, did it? you are new, intelligent and have knowledge that apparently others there don't have. you are seen as a threat. you might know too much to be able to tone it down. in that case, a better organized, more knowledgable company may be your best bet. Good Luck! you'll find your nitch.

[Ruas61, BSN, RN]

Primary responsibility for accuracy lies with the person selecting the MDS item response. Each person completing a section of the MDS is required to sign the Attestation Statement (AA9, AD, and AT7) that reads:

�I certify that the accompanying information accurately reflects resident assessment or tracking information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from Federal funds. I further understand that payment of such Federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.�

This is what I base my practice on. It would be interesting to see how people interpet it.

[itthybitthythpider]

Thanks very much, great advice. You are so right, I did document, and I asked for minutes in every meeting as did the MDS nurses,and then we asked,and asked. Higher ups got it all straightened out,and we are now full speed ahead. So glad we didn't really have to default. Administrator was very,very pro-active on this one. Think the team is now going to be really great!

Glad it worked out! You sound like someone the facility needs to whip them into shape!

[pixie120]

Pixie, you are smart and you are passionate. tread lightly, do the MDS nurses report directly to you? or do they have a corporate, regional/district sometimes consultant like person? I've seen you from other posts under MDS and am an MDS nurse myself, have been an ADON, offered DON (wouldn't think about it ;-)

and no, i don't feel that submitting an assessment without all the information is fraudulent, submitting incorrect information knowingly is fraudulent. If an assessment will be late if you don't submit and you can't get the information you need from therapy, it doesn't change the assessment, only the reimbursment. If there is a regional/district whatever MDS person, he/she should get involved. Issues such as these are going to make a BIG BIG difference and you're right, it didn't take long, did it? you are new, intelligent and have knowledge that apparently others there don't have. you are seen as a threat. you might know too much to be able to tone it down. in that case, a better organized, more knowledgable company may be your best bet. Good Luck! you'll find your nitch.

Appreciate your post, somehow I didn't see it until today.You are so very right, I can't hide what I know....sad isn't it? I am interviewing for several jobs in the area in companies that seem to have a much better handle on this. I will make sure going forward, the support system is in place to make the job easier. THAT has been my lesson this year, lol!