mdsNurse2016

Check out MDS Assistant for IOS, it is something I have been using MDS Assistant MDS Assistant on the App Store

An auditor is not the final decision maker. I would wait for the final results of the Audit and then Appeal it should her decision stand. . Hopefully you saved the started OBRA assessments that you were unable to complete due to the resident's medical condition. I would explain the situation. Provide your evidence and cite the RAI. Use their own guide against them. If a resident had an OBRA Admission assessment completed and then goes to thehospital (discharge return anticipated and returns within 30 days) and returns during anassessment period and most of the assessment was completed prior to the hospitalization,then the nursing home may wish to continue with the original assessment, provided theresident does not meet the criteria for a SCSA. In this case, the ARD remains the sameand the assessment must be completed by the completion dates required of the assessmenttype based on the timeframe in which the assessment was started. Otherwise, theassessment should be reinitiated with a new ARD and completed within 14 days after re-entry from the hospital. The portion of the resident's assessment that was previouslycompleted should be stored on the resident's record with a notation that the assessmentwas reinitiated because the resident was hospitalized. If a resident is discharged prior to the completion deadline for the assessment, completionof the assessment is not required. Whatever portions of the RAI that have been completedmust be maintained in the resident's medical record.3 In closing the record, the nursinghome should note why the RAI was not completed. 3 The RAI is considered part of the resident's clinical record and is treated as such by the RAI utilizationguidelines, e.g., portions of the RAI that are started” must be saved. (RAI, 2-17)

There's no changing the rules of the RAI, so where you need to look is at the ADL documentation. We all know that there is ALWAYS inaccuracies with ADL coding. When I see coding that doesn't seem right I head straight to the direct caregivers. I ask very specific questions about care provided. Most of the time I do find that they have not taken credit for the care they provided. The CNAs know if I am walking down the hall I will be watching them and asking questions. It may sound tedious, but completely worth it in the end. I also pull the nurse managers into my education. ADL coding requires continuing education and monitoring; however, your work will pay off in the end.

Check out MDS Assistant for iPhone, has a complete OBRA Calendar/Calculator. Plus some other features like ARD-lookback PPS-Schedule Calculators.

Check out MDS Assistant on the App store MDS Assistant on the App Store