MDS Alert

Don’t get tunnel vision — look for improvements, not just declines.

The right situation in which to initiate a Significant Change in Status Assessment (SCSA) isn’t always clear-cut — and in some cases, it can practically become a guessing game. Here are the most common errors that you’re likely making from time to time regarding SCSAs:

1. Understand What ‘Significant’ Really Means

“I think one of the most frequent mistakes or errors that providers make in regards to the SCSA comes down to the determination of whether the resident qualifies for the assessment or not,” says Scott Heichel, RN, RAC-CT, DNS-CT, Director of Clinical Reimbursement at LeaderStat (www.leaderstat.com). And misinterpreting the term “significant” could be the root of this overarching problem.

The word “significant” could cloud the thinking of MDS personnel and the interdisciplinary team (IDT) when they’re reviewing a resident, Heichel notes. Although the word “significant” evokes an event that is dramatic, heavy, or major, the definition is actually “sufficiently great or important to be worthy of attention; noteworthy.”

“To the end user, that definition would imply that there is something important going on with the resident and it is requiring our attention,” Heichel explains. “I think if MDS personnel look at it this way, in combination with the RAI-defined requirements of the SCSA, the assessments would be completed more appropriately, and therefore, more frequently.”

2. Don’t Complete an SCSA Before an OBRA Admission Assessment

The RAI Manual is clear on the instruction that you cannot complete an SCSA before you’ve completed an Admission assessment. This rule doesn’t stop some people from making this all-too-common mistake, however.

Example: A resident is admitted to your facility and shortly afterward (less than 14 days) sustains a fall that causes a fracture resulting in a change in his Activities of Daily Living (ADL) status and a discharge to the hospital. In this case, you will most likely discontinue the completion of the Admission assessment, notes Gloria Brent, RN, President and CEO of MDS Consultants LLC in Rochester, N.Y.

If you did not complete the resident’s Admission assessment prior to his discharge to the hospital, then an SCSA is not required upon his return, Brent instructs. Instead, you will set the new Assessment Reference Date (ARD) for the resident’s Admission assessment upon his return and “you do NOT complete an SCSA until after an OBRA Admission assessment has been completed.”

This is true even if you completed a standalone five-day assessment that you submitted to the Centers for Medicare & Medicaid Services (CMS). Therefore, the resident’s baseline level of care will be set after the fracture, Brent notes.

3. Know How Many Areas of Decline/Improvement are Needed

Keep in mind that the RAI Manual instructs you to complete an SCSA when the IDT notes “two or more” areas of either decline or improvement, Heichel says. But you may also complete an SCSA even if the IDT notes only one area of change.

“In this instance, the IDT is required to note in the medical record their rationale for completing this SCSA that does not meet the standard definition requirement,” Heichel stresses. And additionally, you may also complete an SCSA “when the resident shows a consistent pattern of changes, which may include two changes within a particular domain, such as two areas of ADL decline or improvement.”

4. Avoid Rushing to Initiate an SCSA

“Oftentimes, when a member of the IDT thinks the resident is a significant change, they seem to feel rushed to initiate that MDS and get it completed,” Brent points out. But remember that if the resident is in an acute phase of illness (such as receiving antibiotic therapy for a UTI or other illness), the resident may have a decline but there is anticipation that he will make a full recovery.

“Allow up to two weeks (14 days) for this resident to fully recover prior to initiating the SCSA,” Brent advises. “Once you determine that the resident is truly an SCSA candidate, write a note in the record that the team has made this decision and why. This will start your 14-day period of time for completion of this assessment.”

And don’t put the ARD on the date you make the decision to do the SCSA, Brent suggests. Instead, place the SCSA on Day 5 through 8 after the determination, with the completion date by Day 14. This will provide staff with more time to complete interviews and gather data.

Remember: “One of the major purposes of the SCSA is to give the IDT the opportunity to reevaluate the resident, reassess the resident, and rework the care plan so that it more closely resembles the needs of the resident in [his] current condition,” Heichel notes.

5. But Look Deeper for Missed Qualifying Changes, Too

Chances are, however, that you are more often missing SCSAs than completing them when they’re not necessary. “I do feel that there are many residents who meet the RAI definition of an SCSA, but the assessment is not completed appropriately,” Heichel notes.

As the IDT evaluates the resident by comparing his current condition to the status represented by the most recent comprehensive assessment and any subsequent quarterly assessments, you should use the lists on pages 2-23 and 2-24 of the RAI Manual as a guide (see “Look For These SCSA-Triggering Scenarios” below).

Typically, you might fail to complete an SCSA when the IDT is “downplaying what they perceive as minor or little changes in the resident’s condition,” Heichel says. “They may be looking at the resident on the surface and not noticing the changes that have occurred since the last review. If a provider went resident-by-resident with the list of qualifying items, I would not be surprised to see that they determined that a high percentage of their current residents qualify and are entitled to an SCSA.”

6. Don’t forget about improvements. Finally, make sure you’re not just focusing on declines in functioning or a resident’s worsening status.

“Often staff forget to complete an SCSA for improvement,” notes Carrie Bustamante, LPN, MDS Completion Nurse also with MDS Consultants LLC. “When a resident is discharged from therapy and has made gains and improved [his] level of functioning, an SCSA is required at that time as well.”