edhcinc

Hi. Re: COT Yes, we have to evaluate the NEED FOR a COT OMRA each 7 day period following a rehab RUG assessment. Day 1 is day after ARD. We can only be SURE if COT is needed (rehab RUG goes up or down) on day 8. If needed, ARD must be day 7. You can set ARD FOR A SCHEDULED assessment before a COT might be due. It is truly a confusing and burdensome system. AHCA is offering a free webinar this Wednesday. Maybe a different explanation will clarify. Go to AHCANCAL.com website and look around for education programs.

Hi. Maybe an approach that the TEAM needs to know the days/minutes could work. Just like the team would to know daily if a patient was still on a vent and being suctioned, the team needs to know rehab days/minutes daily. Total/cumulative minutes for a 7 day lookback MUST be available the following day in case the ARD must be moved. Good luck, because it will only be getting more & more complicated!

Hi. Many facilities don't expect any higher level of clinical practice from a registered nurse as from a licensed practical/vocational nurse in ANY role. And they may have no idea how a registered nurse with a MSN can be more valuable than one with a BSN or AD. IF you can clearly explain how your ability will help the team and the client holistically analyze problems/symptoms to produce and evaluate a more individualized and "better" plan of care (and produce "better" outcomes) then you should be able to ask for, and be paid for, your skills. This approach would probably work best in a not-for-profit facility. And the MDS coordinator job description may need some serious "tweaking". Many professionals working in nursing facilities have advanced degrees--social workers (MSW), recreational therapists, physicians, nurse practitioners, and physical therapists (their licensure will require a doctorate level preparation in the near future). So good luck!

Hi. Each facility needs to decide whether a unit manager position manages CLINICAL care on the unit or is a highly paid unit clerk. Too many facilities put this person into the situation described by nursemel11. What a waste of professional skills which our more complicated patients need! The RN unit manager must function as a professional nurse--and should assess patients, work with the patient (and other IDT members) to plan his/her care, assure care is given, evaluate the outcome of care given with the patient, assure staff is trained, performing and supported, and assure clear and open communication amongst/between all unit staff. Hire a unit clerk to schedule appointments/transport, stock supplies, etc. Good luck!

Hi. The MDS 3.0 used during the RAND research and pilot study was very different than what we have now. It had less data items, easy to complete and understand ADLs, lookback on most items was 5 days (it takes almost 25% more time if the lookback is 7 days), special treatments/programs had a 14 day lookback (regardless of setting) and other variations. Nurses received extensive training by psychology professionals on interviewing techniques. The study had no mention of scheduling/completion "hassles" because the nurse completed the entire MDS in most cases. SO YES--the originally tested draft MDS 3.0 (full--no RAPs/CAAs) took less time than the MDS 2.0 did. The RAND report can be found at http://www.cms.gov/NursingHomeQualityInits/Downloads/MDS30FinalReport.pdf The RAND study appendixes can be found at: https://www.cms.gov/NursingHomeQualityInits/downloads/MDS30FinalReportAppendix.pdf Then CMS added and changed particular data items and added multiple new payment assessment types. Most (if not all) of the additional and changed data items were in response to MEDPAC recommendations for "more accurate" MC PPS reimbursement. The discharge "assessment" type was added to try to capture discharge status for potential QMs and upcoming P4P initiatives (but falls short, as the resident status is NOT the status AT DISCHARGE--it includes the same lookbacks and is not useful to any receiving facility). Oh yes--On/Off hospice requires a significant change comprehensive assessment even if one was completed 4 days ago, all orders and CP were changed to reflect the resident's terminal status and care, and included that hospice would begin when family returned from vacation to sign the hospice option form. Despite skip patterns, there are more data items on the current MDS 3.0 than the MDS 2.0. We all know the outcome--more data items, more assessments, more complicated scheduling, less time for planning and providing care and less time to complete an "accurate" assessment. The times mentioned are about what my many colleagues have reported (and does include some "hassle" time)--but does not include the time spent by other professionals.

Hi. There is NO CHANGE IN THE PROCESS. Complete the MDS. Certain "care areas" (used to be called "resident assessment") are "triggered" based on MDS entries. Analyze each care area triggered (or holistically analyze all care areas triggered) by considering objective and subjective data that you may gather from wasting your brain completing the individual CAA worksheets OR considering other clinical guidelines. The entire IDT--including the physician--should consider what they already know, or what testing/data/information they might still need to gather, to state the findings as possible or actual client problems. This "thought process" is either written as a CAA summary (just like the RAP summary) or noted elsewhere in the medical record (and cross-referenced for location of information.) If you want to use the checklists, just like with the RAP questionnaires, you will have no brain power left to actually THINK how the parts of the puzzle fit together. How could you have the care plan all written unless the client (or client representative) agrees with your analysis, "problem" definition, and believes that this is something he/she wants to fix, restore, or ignore? Good luck! DO make it a "new" process--by allowing yourselves time to THINK and PROCESS and truly individualize a "problem" and care.

Hi. Having a condition or disease does not necessarily mean that the person requires daily direct care or monitoring/assessment by licensed staff to take care of it. Can think of no situation where a blister on a foot, of or by itself, would require daily skilled monitoring or care.

Hi. The MDS 3.0 is NOT yet final. The RAI Manual for MDS 3.0 is NOT yet final. Contrary to what we may read on listservs or newsletters, information on handouts given out and discussed at a CMS inservice may change and NOT make it into the final RAI Manual. Details that were emphasized last month may be emphatically replaced by different details next week. CMS has issued updates and revisions and revisions of updates. Certain MDS data items are still being closely scrutinized. Best strategy for now? Work on team communication and cooperation. Work on team problem (triggers or CATs) identification and analysis with each other and with the resident/family. Decide on clinical guidelines you will use or reference. Get used to the form, who will do certain sections and when, but don't get "stuck" on each and every word in the Manual--YET. Take up yoga or tai chi and spread the essence of lavender...

Hi. You did not say the number of beds at your facility. Neither did you state how long the situation might last. Tis a terrible idea, under almost any circumstances, but could work for a SHORT while if the LVN is trained in completing the MDS 2 and 3 and there another RN floating around somewhere to assist in an emergency situation. If you have never been a DN, forget it. It is far too much liability, and neither job will be done properly. Good luck in working with your administrator to devise a workable plan!!

Hi--and that is also the answer to your question--HIGH resistance. If you are just starting in that position, please be sure you understand the "territory" before you "lay down the law"--especially since you don't KNOW (or make) the facility's law or the "territory" and its sinkholes, potholes, sandtraps, political (professional) boundaries, or "camps." Is there a facility policy or procedure about MDS completion? They may state that the MDS coordinator will complete...There are many "models" used by facilities to complete the MDS and analyze triggered care areas and other problems found during clinician's assessment. Do all disciplines have access to the MDS software? Do all disciplines have easily accessible computer terminals? Have all disciplines been trained on how to use the MDS software? Do they know how to use their own notes to fulfill RAP summary requirements? Does the team know how to put together triggered RAPs and state one problem instead of many? Do they the MDS-specific definitions ? The MDS coordinator cannot "supervise" other clinicians--or "tell" them what to do. In most facilities the clinicians who assess and plan care with the resident are supervised by the administrator. So go in on Monday--meet with YOUR supervisor. Look at policies/procedures. Talk with your colleagues. Take time to establish professional relationships. Educate the administrator/DN if needed. Is the administrator in support of changes and committed to support and supervise his/her staff? Your task is not easy. We all need to remind ourselves sometimes that we deal with patient problems, not dietary problems, social service problems, rehab problems or nursing problem. Any patient problem (and the patient needs to agree that it IS a problem) requires analysis by all. Good luck!

Hi. Isn't it amazing how nurses are now responsible for understanding and implementing all aspects of ANYTHING/EVERYTHING related (vaguely or not) to the MDS or PPS? As to the generic notice... The Generic Notice is required to be given at least 48 hours in advance if services that the person may elect to receive no longer meet MC criteria--the person has the option to continue to receive the services and self-pay. In #1 you don't need to say that you are giving less than 48 hours because the person could still be eligible if the resident/family had not requested discharge before the 48 hour period had ended. In #2--I would not give a Notice because, as you stated, the person was still eligible for skilled services and the facility has no plans to discontinue--but the person will not be in the facility to receive them. Notes from rehab and social services should explain the circumstances. Good luck! (see FFS Revised ABN Beneficiary Notices Initiative (BNI) for a link to the abn manual)

Hi. Your suggestion is a good one! (just don't get too mad with yourself in September 2011!!) Here's a few more suggestions: Be sure our co-workers--social service, activities, dietary, etc.--understand their new responsibilities and interviews. Who is going to do what and when? Relate each interview to an admission (or annual) history/review/progress note. Develop signs, large print responses, large print vision tests, etc. NOW Inform physicians and mental health team about the PHQ9. Do they want to be notified of any/every score? Are there any clients that they do NOT want us to interview with this tool? Discuss with nursing assistants--let them know what kind of new information we will be collecting. Be sure they understand about the change in recording INDEPENDENT--no help at all, ever, of any kind. Do a few parallel assessments NOW. If there are items that are not understood or truly problematic, let your state RAI Coordinator know NOW. Get a feel for the REAL amount of time it will take to complete. Good luck to all of us!

Hi. Even though the medical record (and I3 on the full/comprehensive MDS) contains a diagnosis which clinically justifies an antipsychotic, there are only specific dx that "count" as appropriate for the QI/QM--they are listed in the QI/QM manual. (and the list is years old) RE: MDS QIES and diagnoses. The MDS system stores all diagnoses recorded at I 3 a thru e. If you change a diagnosis listed at I 3 a or b on a quarterly, that diagnosis is replaced by the new diagnosis--c thru e remain, and can only be changed if changed on the next full/comprehensive MDS. Hope this explanation helps.

hi. as most of you are aware, cms in the process of updating the rai manual. these updates will include modifications already announced via q & a's and train-the-trainer conferences, as well as others that cms deems appropriate. one of the proposed changes-- (summarized and paraphrased) do not follow npuap pressure ulcer staging guidelines. require mds-specific definitions for coding of suspected dti in evolution and stage ii ulcers. information npuap--suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. change to--remove or blood-filled blister suspected deep tissue injury: purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear. the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. and npuap--stage ii: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. may also present as an intact or open/ruptured serum-filled blister. change to--add blood stage ii: stage 2: partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. may also present as an intact or serum or blood-filled blister. issue accurate ulcer staging using agreed-upon clinical guidelines is the basis for statistics, research, outcome measurement, and treatment protocols. in my opinion as a clinician, there is no legitimate reason for this change--and it would make my job harder as i try to explain to the er, a surveyor, a family member or a jury that "...this stage ii wasn't a real stage ii--it was just "accurately coded" that way. we had all appropriate preventative and therapeutic programs in place--and knew that it would evolve into a stage iii or iv no matter what we did..." clinicians in all healthcare settings must use the same clinical terminology whenever possible--and trust that the terminology has the same meaning across settings. cms is still evaluating whether or not it will change the coding definition. please send your comments as a clinician to cms at [email protected] now. use as subject--coding of pressure ulcer stages body--please indicate whether cms should or should not follow npuap definitions in reporting/recording pressure ulcer stages in the mds 3.0. thank you.

We should frown on surveyors who frown on nurses who practice nursing! Most MDS coordinators would love to teach their DN/ADN how to complete the MDS--and to "savor" the "rush" of completing 6 admission, 1 SCSA, 10 quarterlies, and 6 PPS MDS with social worker on vacation, new rehab director, and July 4 holiday...