RN 4 Life

I agree with Talino and poohmdsnurse....in addition you can also be an advocate for the patient and their family by helping them make the best decision. Determine if the patient will be eligible to use both Medicare Part A and Hospice benefits. The patient may be eligible to continue to use their Medicare Part A benefit and Hospice if the primary dx and reasons for treatment are different and unrelated. For example, the patient is skilled for Medicare Part A for the daily care of a Stage 4 wound which requires aseptic technique and prescription medication...and will be admitted to Hospice with a primary diagnosis of end stage renal disease.Use the resources Talino provided to review these concepts in more detail. If the family is not eligible to use both, help the family make an informed decision regarding whether to proceed to hospice. Make sure they are aware that Hospice only covers treatment and services related to the primary diagnosis, pain and some other Hospice related care and services. Probably more importantly from a financial perspective [which can be a determining factor for most families] Hospice does not cover room and board and any medications that are not related to the primary diagnosis that the family may want the patient to have. This can cost the family a significant amount of money if they do not have a secondary payor to absorb the cost. I hope this helps.

I agree, while I have not taken the course, I believe it would prove ver beneficial...once you have had a little time to work through things on your own. Waiting 6-9 months after you start the position as an MDS coordinator will give you time to learn the basic concepts and terminiology you will need to make the 3 - day course truly valuable to you.

This can be especially challenging when the therapist do not understand the role they play in reimbursement for the center/facility and completing the MDS. I would try talking to them first telling them the importance of the information you need, second I would try to determine why it is difficulty for them to provide you an ARD. Could it be they do not plan therapy treatments, could it be insufficient staffing which leads to inconsistent treatment...these are just a few reasons both of which can be worked around. Next I would just set the date for them. Begin by asking them what level of rehab they believe the resident/patient will need. Then look at the patients MDS calendar and pick a date that allows the therapist to achieve the 5 days and ____ minutes they need. It is good practice to meet with the therapy director daily or at least every other day to determine if the therapist are on schedule to meet the patients rehab minutes. Doing this will allow you to plan ahead and move the ARD if necessary before it is too late. This may seem like a lot of work but it will save you time in the long run. I hope this helps..check back in and let me know.

I would say there is a huge learning curve for becomeing a MDS Coordinator. It takes about 6 months to grasp minimal competency and then another 6 months to begin mastering your skills and develop critical thinking skills. AANAC is a great resource. I would recommend waiting until you have been in your position a few [6 months would be good] months before taking the certification course, so that you can really absorb the information you are taught. Otherwise it may be overwhelming. I think you definetly have to develop some stress releavers or you will go insane. Venting on these nursing blogs seems to be a good way to relive stress. Good Luck in your position.

The MDS Coordinators report directly to the administrator, although they receive guidance from internal consultants who also influence how they do on their annual evaluations.

I am glad to see you hung in there. There is a big learning curve to be a MDS Coordinator and an even bigger learning curve to be a successful one. Are there any specific questions you have about scheduling? I'd like to help you if I can....

The MDS 3.0 is going to a poweful tool. Its ability to help us assess and collect data regarding how our patient is doing is going to change to face of care in the nursing home. I do believe that people are afraid of having deficent practices in theree nursing homes so they push excessive documentation to prove we are doing all we can. In my opinion, the MDS 3.0 puts us one step closer to a facility where meeting the needs of the patient [despite what they may be]are at the top of the list. Which is truly what culture change is all about. Additionally, I think it is important for us as nurses in LTC to advocate for the things we need to make culture change successful. Policy reform is also apart of our responsibility. Do you communicate with your legislature your concerns? There are many strong opinions within this thread that deserve to be heard by the local health care advocates. They are our voice..so we need to consistently communicate with them.

How are things coming along? How are the patients and their families responding and how is the staff adjusting. I think your facility taking the best approach to implementing culture change.

It is now March 14th and I am wondering how you are making out? Have you got your first Medicare patient yet? Do you have any questions? Let us know how you are doing?

I am a member of AANAC, AANEX and allnurses, I like them all. But I have to say allnurses is my favorite. I like all the extras such as the Thank You's, ability to email privately, how you can rate a thread. I also like how you have full control of what you read. You will find that there are several MDS folks who belong to both sites and will share there experience here as well. Since you are new, get familiar with this site and see what's out there! Enjoy.

you are correct, it does not state that as a specific reason for there use, but i do believe the intent is to allow some flexibility to the patient and the staff. not making the rules so strict that someone should loose a rug category inadvertantly. as i am sure you are aware [but for new mds coordinators] grace days can also be used in the case where the mds coordinator is absent or ill [rai manual chapter 2 2-28], or to spread assessments out if too many fall on one day. while they should be used sparingly, as stated in the rai manual, the use of grace days allows clinical flexibility in setting the ard and they can be used to more fully capture therapy minutes and other treatments.

As an MDS Coordinator it is part of your responsiblity to maximize reimbursement. I think sometimes nurses feel this is a negative thing and look at it as shameful. Yet, it is a very important part of allowing the facility/center to pay for the care and services the patients need. Nothing is for free, especially healthcare! I also look at it as a way of advocating for the patient. Everytime I utilizie my patients Medicare benefit I look at it like I am giving them something that they are not only entitled to but that they have worked there whole life for. Dont be afraid to use grace days, just use them as the regualtions allow us to use them. If you are in this role, maximizing reimbursement is your responsiblity and it is important that you become good at ways to do it....for you, for your patients and for the center/facility you work in. If you are grounded by your strong ethical beliefs to do the right thing, you will likely develop the good practices and use the grace as they have been intended......Dont be afraid to use Grace Days ;-)

I am just wondering whether or not you accepted the position and how things are going so far. I do know of several LPNs who are MDS Coordinators and they are all very very good. They maximize revenue for there facilities and they have no problems because the DON or the ADONs sign the MDS for them. Some people may view this as an inconvienence but I view it as team work! There are many great resources available to you. Please use the experience of those here to help you as you gain experience.

below is an excerpt from the federal register detailing the appropriateness of grace days. ultimately it is appropriate to use grace days to more accurately capture therapy minutes or other treatments. it is not illegal to use day 8 to capture an ultra high rug category, in fact, as stated below it is another reason grace days were made available. please see below specifically the identified areas in red for more detail. http://vlex.com/vid/23327224 link for: medicare: skilled nursing facilities; prospective payment system and consolidated billing. g. mds scheduling requirements 1. grace days comment: we received several comments asking about the appropriate use of the 3-day grace period provided for the medicare 5-day assessment. there is some confusion about when use of the grace days could result in the facility being at a high risk for an audit. response: days six, seven, and eight, of the medicare covered stay, were provided as grace days for setting the assessment reference date for the medicare 5-day assessment. this assessment is to have an assessment reference date (mds 2.0 item a3a) of any day one through eight of the medicare part a stay. days one through five are optimal but days six through eight are also acceptable, and for some residents may actually be more appropriate; for example, to allow maximum flexibility for nurses to determine when to set the assessment reference date for the beneficiary's mds, and thereby lessen the burden of the increased frequency of assessments that accompanied the pps. thus, the resident can be assessed using any one of these first eight days as the assessment reference date for the medicare-required 5-day assessment. however, we discourage the routine use of grace days for assessing every medicare admission. we plan to identify patterns of inappropriate use as we gain a better understanding of what facilities' practice patterns are. when a facility routinely uses a grace day as the assessment reference date for the 5-day assessment, it loses the cushion that these days provide against performing the mds later than day eight and, thus, risks being faced with payment at the default rate. at this time our main interest is to encourage facilities to perform assessments timely and to recognize the grace days as a cushion and to use them as such, rather than as deadlines for setting each beneficiary's assessment reference date. the grace days are also provided to offset any incentive that facilities may have to initiate therapy services before the beneficiary is able to tolerate that level of activity. our discussion in the interim final rule about the possibility of audits was intended to address the possible practice of routinely using grace days for medicare assessments. we were cognizant that the routine use of a grace day for the 5-day assessment would pose a temptation to back-date the assessment fraudulently when day eight was missed. we believed that any facility that routinely used grace days for the required assessments was liable to have assessments billed at the default rate; and that the absence of default rate billings in the facility's claims might indicate that some misrepresentation of the assessment reference dates had occurred. unlike the routine use of grace days described above, we do expect that many beneficiaries who classify into the rehabilitation category will have 5-day assessment reference dates that fall on grace days. there are many cases in which the beneficiary is not physically able to begin therapy services until he or she has been in the facility for a few days. thus, for a beneficiary who does not begin receiving rehabilitation therapy until the fifth, sixth, or seventh day of his or her snf stay, the assessment reference date may be set for one of the grace days in order to capture an adequate number of days and minutes in section p of the current version of the mds to qualify the resident for classification into one of the rehabilitation therapy rug-iii groups. another reason for the provision of three grace days for the 5-day assessment was to make it possible for beneficiaries to classify into the two highest rug-iii rehabilitation sub-categories. classification into the ultra high and very high rehabilitation sub-categories is not possible unless the beneficiary receives the sub-category's minimum level of services during the first seven days of the stay. we also intended to minimize the incentive to facilities to provide too high a level of rehabilitation therapy to newly admitted beneficiaries. having these extra few days allows time for those beneficiaries who need it, to stabilize from the acute care setting and be prepared for the beginning of rehabilitation in the snf. we expect facilities will not compromise any beneficiary's health by beginning rehabilitation therapy prematurely or at a level that is too rigorous for the individual's status. in summary, use of grace days is acceptable and permitted for patients with any condition. however, a facility that uses grace days routinely may be subject to audit to determine that assessment reference dates are accurately reflected.

Well, one thing I definetly would not do is have a prearranged idea of when every assessment would be "the first Monday in there assessment period". First look at the type of assessment you would be completing. I think you are on the right track by looking at the patient in terms of what you can capture. I look at the MDS as a picture. In the picture it is important to capture as many resources provided as possible. So you are doing the right thing by moving the ARD date. Some things that might help you in the future: 1. Before setting the date- listen to report, read the 24 hour report for all the patients who will be due an assessment. 2. Determine if they are experiencing an increase in there needs: ADLs increased, increase in MD orders or visits, Med changes, or any instability. 3. Also look at indicators that will increase your RUG score: administration of IV meds, IV Fluids, Rehab, Wounds, UTI, skin tears, Suctioning, Trach Care, O2 administration, Blood Transfusions.... 4. Then set the ARD. Sometimes these events may not have occurred and you will have to guesstimate...but if the resident/patient is sick than you will very likely capture all or most of the resources by selecting an ARD close to the time these events began to occur. Many of the items have a 14 day look back period. Begin by looking at everyone who is due an assessment in the next 30 days. If they have something going on set there date....remember it is okay to set Annual and Quarterly dates a little early. I hope this helps.