at what point can you NOT do an assessment?

[crissrn27, RN]

We had a resident discharge AMA after a 6 day stay. An ARD was chosen (day 8) but he left before it was reached. The nurses had done good documentation, good assessments, etc. The MDS nurse at the time missed doing the 5 day. She did a discharge before initial assessment. It is now about 4 weeks later. The powers that be said we can't do an assessment at this point b/c the mds nurse didn't assess. We do assessment all the time without assessing b/c of situations like these (resident leaves before ARD reached, came in on Fri and discharged on Sun, etc). Can't really find any info on CMS website with this specific problem. Anyone have any insight?

[Nascar nurse, ASN, RN]

Is is safe to assume that the resident was medicare since you mention doing a 5 day? I don't get why you can't just move your ARD if you have all the documentation to support the new date. Nothing states you can only use assessment done by the MDS nurse. Why would you want to be at the default rate for 5 or 6 days?

[amylpn24]

In this case, you would change the ARD to the day of discharge. There is nothing in the RAI that says that the MDS nurse must do an or the assessment. You just use what information that you have from his six day stay and hosptial records and answer the questions that best that you can. The powers that be are incorrect and as mentioned by someone else, they will be taking the default rate. Not wise.

[crissrn27, RN]

I didn't think it would be a problem, but they wouldn't let me do it. I am now the MDS nurse again (after a stint as DON, during which I discovered I am an MDS nurse, not a DON, lol) and didn't want my building to have to take a default rate, but our cor. medicare guru said we had to. Oh well, guess they need better folks, I can't even get a raise so I won't worry about it too much, lol. I make less than some of the LPNs that work the floor and have much less experience as a nurse than I do, but I'm stuck at this point (I'm in the early stages of a very high risk pregnancy, and need my STD, vac. time, etc). These people are the most penny wise, pound foolish I have ever seen.

Thank you guys for confirming that I'm not crazy!

[Talino]

it is now about 4 weeks later. the powers that be said we can't do an assessment at this point b/c the mds nurse didn't assess.

correct!

rai p2-37...

resident expires or is discharged

if the beneficiary dies or is discharged before the eighth day of covered snf care following the initial admission from the qualifying three-day hospital stay a snf must prepare an rai as completely as possible to assign a hipps rate code for medicare payment purposes within the required assessment schedule. if no rai is completed under these specific circumstances, the snf may submit a claim using the hipps default rate code. a stay of less than eight days that does not meet these requirements requires the completion of an mds to receive payment; the snf cannot bill the default code.

since there was no assessment done, you cannot even bill at default. the facility will have to eat the bill.

[crissrn27, RN]

Thanks Talino, but who is correct? I suggested doing a 5 day with ARD of day of d/c, and of course closing it for the date it was actually completed. Could we have done that? They said they could bill default without an assessment b/c the stay was under 8 days, but the info from CMS seems to say the exact opp?

[Talino]

Cris - It would not be appropriate to set an ARD if the window allowed had already passed. You may complete a late assessment w/ today's ARD and bill at default if the resident is still in facility.

The excerpt I cited from the MDS 2.0 RAI is quite ambiguous and I'm overreading it, too. In your case, the facility can indeed bill at default without an MDS assessment completed.

In those situations where the beneficiary dies or is discharged before day 8 of the covered stay upon initial admission to the SNF following the qualifying three-day hospital stay, CMS has instructed SNFs either to complete an assessment to the best of their ability or to submit a claim using the default rate without the necessity of completing an assessment.

http://edocket.access.gpo.gov/2008/pdf/E8-17948.pdf p19 1st paragraph 2nd column

[crissrn27, RN]

That makes me feel better that we can at least recoup at default, but I'm still a little confused. Say a resident comes in on Fri and leaves AMA or goes to the hospital or dies on Sun. We would then do an assessment on Mon with an ARD of Sun. Should we not be doing that b/c it would be out of the window? Or is this one of the things we do and just don't talk about, lol?

Don't know why I'm worried about it, October is coming with whole new set of rules and regs very soon! But, in the mean time, I don't want to do anything unethical, or illegal!

[Talino]

Don't forget Monday was a holiday and there was a snow emergency on Tuesday. Oh, weren't you sick on Wednesday? Since the assm't window for a 5-day is day 1-8, you are permitted to create a 5-day and set the ARD on or before DC date even if resident is not in the facility anymore.

Except for the OMRAs, the rules for PPS assessment windows remain unchanged w/ MDS 3.0.

[susanthomas1954]

Technically, can't set the date after day 8, so my rehab director and I have an agreement that if a patient discharges before an ARD is set, we agree IN ADVANCE that the ARD is the date of discharge. We have that agreement as a policy between us, SO, even though the rest of the team may not know it, the ARD was set the second the patient left the facility. Obviously there is no way for CMS to enforce the ARD policy, and some of us may actually set a date after the "deadline," but having this agreement between the rehab mgr and myself serves us both very well.

[crissrn27, RN]

We also have that agreement and also set the ARD on day of admit (we very rarely get sat, sun admits). So, this is a very complex issue. Also, for this resident, we had set an ARD of day 8, but he left AMA on day 6. So, still not sure what I should have done.

[andy3k]

RAI Manual pg 3-30, first sentence, "When the resident dies or is discharged prior to the end of the observation period for a required assessment, the ARD must be adjusted to equal the discharge date." I bolded the 'must'. No decision making required.