Health Information Compliance Alert

Ensure accuracy if MDS sections have not been signed through verification.

When a former employee completes part of the MDS but fails to sign it before leaving your facility, you can expect your workload to increase, according to the most recent Resident Assessment Instrument (RAI) manual revisions.

The manual revisions clarified what to do when someone cannot sign in Item Z0400 — Signatures of Persons Completing the Assessment. This situation can occur, for instance, when a staff member completed, but did not sign for, MDS sections, and is now no longer employed by your facility.

Simply put, if someone cannot sign, you must verify those portions of the MDS, through the medical record and/or by re-interviewing the resident to ensure that information is accurate, according to a recent analysis of the RAI manual changes by the Texas Department of Aging and Disability Services (DADS).

According to the RAI manual, here are the steps you need to take to complete Item Z0400, even when someone cannot sign:

•  Ensure that all staff members who completed any part of the MDS enter their signatures, titles, sections, or portions of sections they completed, along with the date completed.
•  Ensure that staff members identify exactly which items they completed. If multiple staff members complete items within the same MDS section, ensure that they identify the exact sub-set of the item within that section they each completed.
• Ensure that you have proper security measures in place to protect the use of electronic signatures on the MDS. Your facility’s security measures must comply with any and all state and federal privacy and security requirements.
• Review and verify the information to ensure accuracy in every section completed by an individual who cannot sign. Verify the information the individual provided in the MDS by reviewing the medical record and validating the information with staff, the resident, and the resident’s family members. (Person signing the attestation must perform the verification.)
• Re-interview the resident for any resident interview sections completed by someone who cannot sign to verify the accuracy of the information provided. (Person signing the attestation must perform re-interviews.)
• Sign on the date that you performed the verification.