MDS Alert

Make sure you're not doing more than required.

Most people agree that discharge assessments have become a sticking point with the MDS 3.0, especially for certain SNFs.

Doing the discharge assessments becomes "onerous" for a facility with 120 beds and primarily short-stay patients discharged every 33 days, says Sandra Fitzler, RN, BSN , senior director of clinical services for the American Health Care Association, who notes the trade group has members that fit that bill. Fitzler says she's aware that CMS is examining the discharge assessment data to determine the necessary elements for some of the post-acute quality measures.

CMS' Mary Pratt reported in a recent SNF/LTC Open Door Forum that the agency plans to convene a group of experts to take a closer look at the burden imposed by the discharge assessment requirement (MDS Alert, Vol. 8, No. 3). CMS would also like the nursing facility community to look at unplanned discharges to the hospital as an opportunity for quality improvement for them or hospitals, Pratt said. (See page 32 for tips on how one SNF reduced its rehospitalization rates with a nurse practitioner and MD hospitalist team.)

Facilities should also make sure they know the true requirements for doing discharge assessments and when to combine them with other assessments, say experts.

Basics: The facility must do a discharge assessment when a resident is discharged from the facility -- not when he goes off Part A because he exhausted his benefits or no longer requires skilled services and remains in the facility, advises Ron Orth, RN, NHA, CPC, RAC-CT, president of Reimbursement Solutions in Milwaukee, Wis.

You don't do a discharge assessment for a resident who dies. "If someone dies, you do a 'death in the facility' record, which is just like a tracking form," Orth instructs.

Keep in mind: If the resident goes out to the hospital for observation and returns within 24 hours, you would not have to do a discharge assessment, says Orth. That's the requirement for the MDS, he says. Separately, "there's a midnight rule related to billing [where] if the resident is out of the facility at midnight no matter where [including the ED], you cannot bill for that day."

Follow CMS' instructions: "CMS has clearly stated that for an unplanned discharge, you only need to complete the information that's readily available," says Orth. "It's allowable to dash fill the interviews" if you haven't done them. "You might have ADL information and wound information and behavioral information -- information that's readily available in the chart."

"You can combine an OBRA admission with a discharge assessment and/or a discharge assessment with a 5-day PPS or other appropriate PPS assessments if the ARDs fall within" the same acceptable range, says Patricia Newberry, executive director of clinical reimbursement for United Clinical Services-UHS-Pruitt, in Atlanta, Ga. "But you can't replace the admission or PPS assessment with a discharge assessment. That's because the discharge assessment doesn't have all the key elements that the other two have."

Key point: "If you do combine multiple types of assessments, including a discharge assessment, the ARD for the discharge assessment must be the discharge date," stresses Pam Campbell, RN, with LTC Solutions Inc., a software developer in Camdenton, Mo. "That is set in stone and really limits your flexibility."

When deciding whether to combine the discharge assessment with a PPS assessment, says Orth, you have to make sure setting the ARD on the day of discharge for that assessment isn't going to negatively affect your RUG outcome. For example, if you knew a person was going home on day 16 or 17, you could hold off on doing the 14-day PPS assessment until then and combine them, he points out. "But you have to make sure you are not going to negatively impact your RUG outcome by doing that. For example, if you use the day of discharge as the ARD, the person may not have received therapy services on that day." And that could have a negative effect on the resident's placement in a rehab RUG, he points out.