ibtootie

First I just need to blow my stack that no matter how much I instruct and educate the Unit Assistants on ADL documentation, they still either don't get it or don't care to get it. No matter how much I complain to the Nursing Director about it, either she too doesn't get the importance of it, or she doesn't want to! That being said, Mrs. X was admitted to our facility for rehab after a total knee arthroplasty. She was in our facility 7 days and had 8 different UA's assigned to her. Of that 8, only 2 actually documented ADLs. "Bob" is one of the night UAs and had her 2 nights. His documentation is pretty accurate, and coincides with the Nurses and Therapists documentation. "Sherry" is one of the day UAs who had her for 3 days, and her documentation is rarely ever accurate. She often combines self performance and support in ways that are not even logical, such as independent and 2 person physical assist, so most of the time I cant use any of her documentation. I have instructed her and reinstructed her until I am blue in the face, and it doesn't seem to sink in with her. My problem is that there were only five entries for ADLs, and only 2 of those 5 entries could be used. Technically there were more than 3 episodes ADL documentation, but I don't feel comfortable submitting what there is since I know it isn't accurate. Has anyone else ever experienced this, and if so, how did you handle it?

At my facility I do an orientation with the CNA's and participate in the Daily Huddles to pass along tips and pointers for accurate documentation. The SNF CNA's are for the most part accurate in their documentation. My problem, however, is that we frequently have float CNA's pulled from our Inpatient Rehab Facility on a different floor who rush through the ADL documentation, so I often see documentation that bilateral amputees and residents with bilateral lower extremities contractures WALKED in the room and hallways when they in fact DID NOT. When I have adequate documentation from Therapy and Nursing that makes it clear the resident could not ambulate, I code an 8, but always worry that their rushing through is going to cause an inaccurate code.

Generally, the day of discharge, death, or a day on which a patient begins a leave of absence, is not counted as a utilization day. (See the Medicare Benefit Policy Manual, Chapter 3, "Duration of Covered Inpatient Services.") This is true even where one of these events occurs on a patient's first day of entitlement or the first day of a provider's participation in the Medicare program. In addition, a benefit period may begin with a stay in a hospital or SNF, on that day. The exception to the general rule of not charging a utilization day for the day of discharge, death, or day beginning a leave of absence is where the patient is admitted with the expectation that he will remain overnight but is discharged, dies, or is transferred to a nonparticipating provider or a nonparticipating distinct part of the same provider before midnight of the same day. In these instances, such a day counts as a utilization day. This exception includes the situation where the beneficiary was admitted (with the expectation that he would remain overnight) on either the first day of his entitlement or the provider's first day of participation, and on the same day he was discharged, died, or transferred to a nonparticipating provider. Can this rule apply if the Resident admits and then leaves AMA?

In May of this year my computer was exposed to a freak power surge that crashed all of my data drives, causing me to completely lose everything pertaining to jRAVEN, (the system we use) along with any and every document I ever saved. Our facility was able to retrieve most of the information from CMS and we were able to re-upload most past data back into jRAVEN, but the data was incomplete in many of the previously exported assessments. One in particular that was overlooked was an OBRA admission assessment that had been completed the day before the crash. I had it ready to export and printed out a paper copy of the actual MDS assessment showing the completiion date. After the crash, I became so occupied with the task of restoring all the previous data, and overlooked the assessment that had been export ready, but never submitted until the name appeared on the missing assessment list in CASPER. The resident has since discharged. Can the assessment still be submitted since I just discovered the mistake? How will it affect the ARD date?

Resident admitted 2/13 for wound care for an ORIF wound infection and IV antibiotics. Injury was presented as work related even though the resident has MCR, and the claims adjuster preauth'd his SNF stay. I went ahead and set day 8 (2/20) for ARD. OBRA Eval completed and submitted 2/26 (yesterday- day 14) with HIPPS code -60. This morning, Workers Comp is denying the injury is work related and denying the claim in its entirety. Today is day 15, so if I modify it and resubmit it as PPS, I will now have to use todays date as the ARD and it will be considered late...correct?

Resident admitted on 1/3/13 and 5 day ARD set for 2/7/13 (Day 8). The doctor put resident on 3 days of bedrest 2/5, 2/6, and 2/7 (days 7, 8, & 9) and therapy resumed 2/8 (day 10). Does an EOT need to be done if the break occurs in the first 14 days? If so, by setting the SOT ARD on 2/14 (day 16) can I combine the SOT with the 14 day eval, and if that Rehab RUG is higher, will it retro back to day 10?

So if I understand this correctly A0410 pertains to the certified beds, and not the payor? All of my beds are Medicare beds, no Medicaid beds, so I should be answering A0410=3 regardless of the payor for the NC eval? I'm in Texas.

I need some help on this one since it is just found 9 months after the resident admitted and discharged. Mr. X admitted to our facility 3/20/12 for IV antibiotics for a post-op wound infection. On 3/26/12 he was sent back to the hospital for increasing drainage and had an I&D of the wound and returned to us 3/28/12 and stayed in our facility for wound care and IV antibiotics until 4/29/12. At the time, I did a 5 day PPS assessment for his first stay 3/20/12- 3/26/12 with the ARD 3/26/12 capturing a RUG level of CA1-10. Upon his return from the hospital I completed another 5 day PPS, as I was told he had been inpatient at the Hospital, this time again capturing a RUG of CA1-10 with his 5 day ARD 4/4. His 14 day had an ARD of 4/14 and 30 day with ARD 4/28 assessments were submitted and he discharged home on 4/29/12. Today I get a message from our billing dept. that the 2 stays were combined into 1 account under the first stays account number because he had actually been in OBSERVATION status for his 48 hr hospital stay (the one we sent him back for) and not inpatient as originally thought. So this completely invalidates all the dates for the second stay. I am thinking that I should first submit an inactivation record for the entire 2nd stay, since there apparently was no 2nd stay, but rather a continuation of the 1st. Then, create a correction record for the first stay and include all the days, but the 14 day and 30 day ARD dates will be different. Is this right?

I'm curious to know how many PPS MDS evals (all combined) everyone else submits per month. I'm trying to figure out if I am on track, or if I need to speed up. I am at a hospital based SNF -not swing bed, with 20 Medicare beds with an average length of stay of 13.7 days. I feel swamped, but don't have any other past facilities to compare with.

Can you set the ARD date for OBRA NC assessments before day 14? For some reason I thought the ARD date was set at day 14 unless the resident discharged prior to day 14.

Does Safe Harbor apply to SNF's?

That's my main complaint too. It would be great to be able to make changes without deleting everything and starting over. I thought that the changes could be made when the program first came out, but the upgrades along the way got rid of that feature. There may be a valid reason it was removed.

My facility currently uses jRAVEN. When I started they were using RAVEN, so I have never had any other software to compare it to. I'd like to hear from others who have used jRAVEN and how it compares to the other programs out there.

Resident admits from acute care on 11/5 and transferred back to acute care within 36 hrs. I completed NT and ND with A0310F=11-DC with return anticipated. She returned from acute care back to SNF on 11/19. I entered A1700-2=Reentry and submitted scheduled assessments as per routine. My understanding is that if a patient admits and discharges with intent to return to the SNF within 14 days all that is required is NT and ND. Our billing person says that the resident was out of the facility for more than 7 days, so in order to bill for the 36 hr stay an NC should be done. Is this correct?

I have started doing inservices and have reoriented each CNA at least three times, but still find the same errors over and over from the older CNA's. I haven't found any material to cite specific examples, so I used real past patient scenarios (with identifying info removed) and made my own material. I have also been given a 2 hr orientation block to the new hires to try to train them from the start how to code appropriately and demonstrate to them the impact their documentation has on the facility. They seem more interested once they see that their input has meaning, and isn't just "busy-work" for them to complete. Overall, it's been an improvement.

Would that be in the Casper Reports? In Casper Reports there is a link MDS 3.0 QI/QM Reports-Under Construction. I saw that a few moments ago while printing my Validation Report, but it was blank.

Thanks Talino for the link. Still though, if you adhere to the script of the patient interview, it still seems to ask one sided questions. "Have you had ANY pain or hurting over the last 5 days?" yes or no. "Please rate your WORST pain over the last 5 days". There is no question to rate their pain after the pain intervention which could bring their pain relief score to a 1 or 2. Most of our patients are post-operative ortho and they do have frequent pain at a 7-10, but their response to the pain interventions arent captured when sticking to script.

It seems like it would have been simpler for everyone if CMS had just changed the rule to state that everyone receiving Medicare rehab services should have evaluations every seven days period.

My facility has the same issue. When we get post-op patients or patients with infected wounds, I would expect that a resident will say they are having severe pain or 8 out of 10. The problem is that the section J does not permit any inclusion of responses to their pain management. Our facility documents the pain number before the pain medication/intervention, and then documents the number afterward and there is a drastic reduction in the pain number response, but I don't feel like that is being captured in the rather black and white responses to choose from in the assessment.

I recently joined AANAC, and have found that, even though the same information can be found on the CMS website, AANAC's information is far more user friendly and has less "government speak". I am the first to admit that am NOT computer literate, and AANAC's site is easier to maneuver in and out of than CMS.

Yes, I meant EOT, sorry, all the acronyms are starting to run together in my brain. So, in doing a COT because of the change in the RUG level, I will need to reassess in 7 days and do an SOT?

My understanding of the EOT/SOT/COT was that a COT was warranted if the Resident missed 3 consecutive days of therapy but I'm seeing that if the Resident is on only 1 Rehab discipline it would change the RUG if he gets 4 days of therapy out of the 7 day look-back. Mr. X is getting skilled nursing for IV antibiotics and wound care plus Physical Therapy only for ambulation safety with a cane. He receives PT on Monday, Tuesday, Thursday and Friday, and no PT over the weekend. During that 7 day look-back (from Sunday to Sunday because of the way the ARD fell), it shows he had 4 days out of the 7 days of therapy even though there was no 3 consecutive day gap which caused his RUG to go from RMA to CA1. Doesn't that mean a COT eval still needs to be done?

Therapy ended on day #4. Using day 5 as the ARD, He didn't have enough therapy minutes to get a rehab RUG, only CA1. I anticipate that his next RUG will be CA1 also.

Mr. X admits to SNF on 10/11 for IV Antibiotics for Osteomyelitis and foot amputation. Physical Therapy eval deems him too high level in function for PT, but OT determines need for ADL teaching. If Mr. X meets his therapy goals by 10/14 and is discharged from therapy services before the 5 day ARD, but remains in SNF for continuation of IV antibiotics, is a COT required?

So, a COT is not needed if the RUG merely reflects increased therapy minutes as long as the Resident remains in the Rehab category?