MDS Alert

One of the changes is good news payment-wise.

Elisa Bovee, MS, OTR/L, points to what she views as "a very positive change" in the revised RAI User's Manual implemented on Oct. 1. And that is this revision in Section O that states: "For Part A:When two clinicians, each from a different discipline, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full."

"All policies regarding mode, modalities and student supervision must be followed," the manual continues. "The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient."

Bovee notes that "therapy teams often treat patients utilizing two disciplines at the same time to effect change in function on very low level patients." Or they may use the approach for "very high level patients who need realistic challenges prior to reentering the community. This is pertinent for home visits as one major example," adds Bovee, VP of operations at Harmony Healthcare International in Topsfield, Mass.

The revised RAI manual says that "if an unscheduled PPS assessment (OMRA, SCSA, SCPA, or Swing Bed CCA) is required in the assessment window (including grace days) of a scheduled PPS assessment, and the ARD of the scheduled assessment is not set for a day that is prior to the ARD of the unscheduled assessment, then facilities must combine the scheduled and unscheduled assessments by setting the ARD of the scheduled assessment for the same day that the unscheduled assessment is required" (Chapter 6).

"A scheduled PPS assessment cannot occur after an unscheduled assessment in the assessment window -- the scheduled assessment must be combined with the unscheduled assessment using the appropriate ARD for the unscheduled assessment. The purpose of this policy is to minimize the number of assessments required for SNF PPS payment purposes and to ensure that the assessments used for payment provide the most accurate picture of the resident's clinical condition and service needs," states the RAI manual.

"You are allowed to change the ARD during the ARD range, including grace days," says Judy Wilhide Brandt, RN, RAC-MT, C-NE. "So the bottom line is that there cannot be a scheduled MDS in the system with an ARD before an unscheduled MDS in the system when both ARDs are in the window for the scheduled assessment," says Brandt, of Judy Wilhide MDS Consulting Inc. in Virginia Beach, Va. "If you had 'set' [the ARD] and realize you can combine them, you can change that ARD and combine them." (For more information, see the article on page 104.)

The updated manual provides "another example of reasons for an SCSA," says Marilyn Mines, RN, BSN, RAC-CT, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. The example is as follows: "Mrs. T required minimal assistance with ADLs. She fractured her hip and upon return to the facility requires extensive assistance with all ADLs. Rehab has started and staff is hopeful she will return to her prior level of function in 4-6 weeks."

The revisions also include leave-of-absence definitions, says Mines. The manual states: "Leave of Absence (LOA), which does not require completion of either a discharge assessment or an entry tracking record, occurs when a resident has a:

• Temporary home visit of at least one night; or
• Therapeutic leave of at least one night; or
• Hospital observation stay less than 24 hours and the hospital does not admit the patient."

"Providers should refer to Chapter 6 and their State LOA policy for further information, if applicable. Upon return, providers should make appropriate documentation in the medical record regarding any changes in the resident," the manual states.

The manual revisions also "reiterated that entry records must be completed on all residents and must be done so with each admission" and readmission, says Mines. The added language is as follows in Chapter 2:

• The Entry Tracking record is the first item set completed for all residents.
• Must be completed every time a resident is admitted (admission) or readmitted (reentry) into a nursing home (or swing bed facility).
• Must be completed for a respite resident every time the resident enters the facility.
• Must be completed within 7 days after the admission/reentry.
• Must be submitted no later than the 14th calendar day after the entry (entry date (A1600) + 14 calendar days).
• Required in addition to the initial Admission assessment or other OBRA or PPS assessments that might be required.
• Contains administrative and demographic information.
• Is a stand-alone tracking record.
• May not be combined with an assessment."

Editor's note: The RAI manual also includes instructions for the Change of Therapy OMRA (see page 107 of this issue) and the End of Therapy OMRA and End of Therapy-Resumption OMRA. For an in-depth look at the latter two assessments, see the next MDS Alert.

The revised manual, which includes more changes than discussed above, is available at www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage.