andy3k

Some states have a nursing act that requires comprehensive assessments to be done by RNs. In those states, the RN must perform the comprehensive assessment and sign complete. Quarterly and PPS/OMRA assessments obviously don't require an RN to perform. This rule is sometimes disregarded but it exists in some states, never-the-less.

Correct.

The RAI Manual says early assessments are allowed and does not define how early. Therefore, one day after an admission assessment, you could perform a quarterly or annual. The next day you could do yet another quarterly or annual, if you so chose. There is no 14 day requirement as mentioned in the previous post.

Now I'm curious. If there is a PPS tracking form different from the MDS 3.0 PPS Assessment Calculator that is helpful to people then I would certainly like to see it. If someone has a copy then please email to [email protected]. Equally important, I'd like to know what people, facilities, or companies created any forms that are emailed to me. Thanks.

For clarification, The care plan must be completed no later than 7 days after the CAA Process completion date at V0200B2. The MDS completion date at Z0500B and the CAA Process completion date at V0200B2 must meet the MDS requirements for that type of assessment. The only time a care plan can be completed on day 21 of a new admission is if the MDS is completed (Z0500B and V200B2 signed) on day 14. There is no 21 day rule that applies only to Admission assessments. If the admission is completed and on day 10 then the Care Plan must be completed by, and V200C2 signed by, day 17, no later than 7 days after MDS completion.

Hello croppyRN, I'm sorry to hear about your situation. I can't help with the workload management issue but I can recommend resources for MDS help when your regional coordinator is busy. First and foremost, I recommend contacting your state MDS RAI Coordinator with questions regarding anything in the RAI Manual or performing assessments in general. Their email address can be found on the CMS website and you should also be able to find their contact information on your state's MDS website. Many state RAI coordinators used to work in facilities and might have suggestions for workload. Another resource I recommend is the Texas DADS MDS website - some of the information is Texas-specific but it has a lot of information, links to other website, and its own resources that you might find useful.

I recommend you contact your state RAI Coordinator, Cheryl Shiffer, at 210.619.8010 to discuss MN requirements.

MDS 3.0 RAI Manual, page V-6: V0200C2, Date The date on which a staff member completes the Care Planning Decision column (V0200A, Column B), which is done after the care plan is completed. Hope that helps.

I know that at least one software product DOES allow you to distinguish non-Part A PPS-like assessments, but I'm afraid I don't remember which one. If you happen to be on the market for software, ask about this.

ibtootie, you are correct. MDS completed for residents in certified beds require A0410=3. In Texas, residents in non-certified beds require A0410=2.

I found out from a colleague that CMS no longer endorses the following, "marking A0310B something other than 99 for a non-Part A record is incorrect, as well, since A0310B is for Medicare Part A PPS records." They got in trouble with the provider organizations and took it back.

I confirm cwrnracct's post. Two weeks ago, CMS said exactly that on a conference call. CMS also has said in the past that marking A0310B something other than 99 for a non-Part A record is incorrect, as well, since A0310B is for Medicare Part A PPS records. I know that CMS would prefer that Medicare replacement, etc. records be labeled and recorded separately. I have heard of at least one software vendor (don't remember which one) that allows you to mark a record as non-Part A, using a non-MDS field, so that the record never gets submitted to CMS and meets CMS's desire for non-Part A Medicare records to be maintained separately.

The D/C is an OBRA assessment. However, a D/C can never be a "prior assessment" because the only MDS record that can follow a D/C is an entry tracking record. You can no longer set an ARD and complete an assessment for a date after the date of discharge. If the resident admits or returns to the facility after discharge then the entry tracking record is your starting point. The resident admits, or reenters, the facility and falls. On the 5-day, you set J1800 as yes for a fall. If the resident does not fall after the ARD of the 5-day then J1800 on the 14-day would be no since the resident did not fall since the 5-day (the most recent assessment). If the resident then discharges, you mark whether the resident fell after the ARD of the 14-day. If the resident is readmitted, you complete the entry tracking record and start watching for a fall again as of the new entry date.

And you only have 2 days after death/discharge in which to set the discharge/scheduled assessment ARD for the date of death/discharge (SNF PPS Clarifications Memo, March 2012).

I got ninja'ed by Talino.

RAI page 2-51: "Alternatively, the SNF may choose to combine the COT OMRA and scheduled assessment following the instructions discussed in Section 2.10." If the COT RUG would pay higher than the RUG that preceded the scheduled assessment, combining the COT with the scheduled assessment would allow you to collect the higher RUG starting at the first day of COT observation period and all days following. Without the COT, you don't get the higher RUG rate until the scheduled assessment kicks in. Alternatively, if the RUG is lower, you would NOT want to combine the COT and scheduled assessment because then the lower RUG would start paying from first day of COT observation period instead of when the scheduled assessment kicks in.

"Assessment Reference Date (ARD) refers to the last day of the observation (or “look back”) period that the assessment covers for the resident. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period. The facility is required to set the ARD on the MDS Item Set or in the facility software within the appropriate timeframe of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and Medicare-required PPS) and varies by assessment type and facility determination." RAI Manual pg 2-8 It is extremely important to ensure that the ARD is set according to CMS rules, not only to avoid inaccurate assessments but also to avoid potential payment consequences. Facility staff must open up an item set for a resident in the facility MDS software and set the ARD in Item A2300 OR create a hard copy of Section A of the MDS Item Set, entering the resident’s name in A0500 and the ARD in Item A2300. ARDs that are only noted in meeting minutes, PPS calculating tools, therapy logs, nurse’s notes, facility forms, memos, or by any other method not specifically mentioned on page 2-8 of the RAIM3 as quoted above, may NOT use that notation as the ARD in Item A2300. The reason is because the ARD was noted but not set per CMS policy. If the ARD was not officially and correctly documented until now, it cannot be set for an earlier date.

The rules for setting a 14-day PPS assessment are in Chapter 2 of the MDS 3.0 RAI Manual under 14-day Assessment on page 2-46. I'd like to ensure that you have all of the information and resources you need to succeed at MDS. Please be sure to pass this message on to anyone else involved in MDS at your facility. I feel that all these resources are critical to your success at MDS. The CMS MDS 3.0 website has official MDS 3.0 documents including the most current MDS 3.0 RAI Manual, Quality Measure (QM) User’s Manual, and training videos on the various MDS sections. Starting April 1, 2012, you must be using the April 2012 version of the MDS 3.0 RAI Manual V1.08. The RAI Manual V1.08 is incomplete without the errata documents that must be included with the RAI Manual. Version 1.09 of the manual will be out in a week or two - changes are minimal. The link for the current CMS MDS 3.0 RAI Manual is: MDS 3.0 RAI Manual | Centers for Medicare & Medicaid Services and the link for CMS MDS 3.0 Training is: MDS 3.0 Training | Centers for Medicare & Medicaid Services It is also critical that you read the following articles and consider them key MDS documents because they contain PPS assessment clarifications for MDS 3.0 that are not discussed elsewhere. You can find them at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/RUGIVEdu12.html "August 23, 2011 National Provider Call Follow-Up and Clarifications" "November 3, 2011 National Provider Call Follow-Up and Clarifications" "Clarifications to March 2012 National Provider Conference presentation" If you are not currently utilizing the Missing Assessment Report in CASPER then now is the time to start. It is a key part of the MDS quality review process. Every resident listed on that report indicates one or more data quality issues that must be fixed whether it be a missing assessment or incorrect resident demographics in one or more assessments. The https://www.QTSO.com website has an MDS 3.0 link that takes you to the MDS 3.0 Provider User's Guide. The guide explains how to submit your MDS data and pull your reports. Chapter 5 is the most important part of the guide and explains the various errors and warnings you may get on your MDS validation report and what you can do about them. You can also find other MDS resources such as Access Request Forms (to get MDS and CASPER access), jRAVEN free MDS software, and more. Get the phone number and email for your state MDS RAI and Automation Coordinators as they are supposed to be key contacts for your questions regarding all steps of the MDS process. Your state health agency's MDS website may have good information about MDS and your state may have an email list for MDS announcements and state-related alerts.

Therapy days/minutes are included on the assessment, because the assessment must accurately show ALL conditions and treatments in the look-back, but the facility cannot bill any managed care days to Medicare.

I know that people should not combine a 5-day with an SOT unless it is a short stay, but I'm not sure if the SOT would be rejected if it was sent separately with a different ARD. Talino is correct that the 5-day would start paying the therapy rate from day 1, usually rendering an SOT pointless, but what about that 30-day Medicare deadline she was referencing? Is that a deadline for setting an MDS ARD or is that a deadline for beginning Medicare again (via paperwork) and claiming a therapy/nursing RUG?

I believe you are correct. An SOT is optional but necessary IF you want to start getting paid for therapy before the next scheduled assessment RUG starts paying. It would not have been necessary because the 5-day covers the same period of time as the COT except, as you said, there is the issue of the 30-day window. The 5-day seems appropriate because the RAI Manual pg 2-46 specifically says readmission is used when a resident discharges return anticipated to the hospital and then returns, which is not what happened.

The answer to your question is inside this article: . Evaluating Activities of Daily Living (ADLs) includes evaluating all the aspects of the ADL, defined on page G-2 of the RAIM3, as "ADL ASPECTS: Components of an ADL activity. These are listed next to the activity in the item set." The steps for assessment for all the ADLs included in item G0110 and listed on page G-3 of the RAIM3 include the following: . When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed Mobility, determine the level of assistance required for moving the resident to and from a lying position, for turning the resident from side to side, and/or for positioning the resident in bed. . In another example, from either page G-1 or directly from the MDS Item Set for item G0110B, when evaluating transfer, staff would determine the level of assistance required for moving the resident "between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet)." . Recently, CMS staff were asked to clarify the components of a transfer when a sling lift (or Hoyer lift, a brand name) is used. CMS staff responded: if the person is able to perform actions that are part of the transfer (e.g., sits on the edge of the bed and assists with sliding onto the transfer sling; partially weight-bear stands and sits on the transfer sling; or positions themselves in the sling), that would be considered assisting in ADL aspects that are part of the transfer activity. A person who simply folds their hands across their chest or puts their hand on a bar while in the sling lift is not performing actions that can be considered as assisting with a transfer. . The coding instructions from page G-5 of the RAIM3 inform staff that extensive assistance is coded "if resident performed part of the activity over the last 7 days, help of the following type(s) was provided three or more times: -- Weight-bearing support provided three or more times. -- Full staff performance of activity during part but not all of the last 7 days." . Continuing on page G-5, total dependence is coded "if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity. The resident must be unwilling or unable to perform any part of the activity over the entire 7-day look-back period." . Therefore, if a resident folds their arms or places their hand on the bar once situated in the sling lift (an action that is not a component or aspect of the ADL activity of transfer), and if this same resident requires full staff performance of those components that are a part of the ADL activity of transfer every time transfer occurs during the 7-day look-back period, the correct code would be total dependence. Source: The MDS Mentor, September 2012, page 3

Keep in mind that PPS scheduling got more complicated recently due to start and end of therapy, and especially change of therapy. If all you need are the main PPS assessments, and you have a separate tool for the OMRAs, then a simpler form may do, but the forms need to be fairly complex to track both PPS and OMRAs together.

Your state MDS RAI Coordinator or Automation Coordinator (first choice) or state Medicaid agency (second choice) should be able to tell you exactly which CMI set is being used for Medicaid payment. Those same people can help you understand why you are getting the RUG/CMI that you are getting if you do not understand why a resident is getting a certain RUG/CMI. Always keep in mind whether or not your state Medicaid uses Index Maximizing for Medicaid RUG calculations.

If I had to depend for food on all the steak dinners I've been offered, I'd be starving. *smile*