MDS Alert

Residents’ families may hope to take their loved one out of the facility to celebrate a holiday, but you can navigate these leaves of absence with ease.

You may be looking forward to the holidays but not feeling joyful about figuring out how to document residents’ out-of-facility celebrations.

Define Leave of Absence

With the MDS dependent on particular dates —  and facilities dependent on the reimbursement that results from evaluating those particular dates — figuring out how to document or bill a day that the resident does not spent wholly in the facility can be difficult. But that difficulty shouldn’t take the cheer out of the resident’s holiday plans or put that resident on your personal assessment submission naughty list.

Look to the RAI Manual for specific guidance on what, exactly, constitutes a leave of absence — and when myriad tracking forms are necessary or superfluous.

The RAI Manual defines a leave of absence (LOA) as 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.”

The RAI Manual notes that a LOA, as defined above, does not require “completion of either a Discharge assessment or an Entry tracking record.”

These leaves of absence are sometimes referred to colloquially as skip days.

Understand Medicare’s Role

Things get trickier when figuring out whether a resident covered by Medicare jeopardizes his benefits by temporarily leaving the facility. Basically, the Centers for Medicare and Medicaid Services (CMS) encourage compassion for residents, especially for special situations like holidays or brief visits home.

The Medicare Benefit Policy Manual: Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance provides guidance on how to evaluate special circumstances like a resident leaving for a holiday meal:

“The ‘practical matter’ criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements, but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, the fact that a patient is granted an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. Where frequent or prolonged periods away from the SNF become possible, the A/B MAC (A) may question whether the patient’s care can, as a practical matter, only be furnished on an inpatient basis in a SNF. Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences. (See the Medicare Benefit Policy Manual, Chapter 3, ‘Duration of Covered Inpatient Services,’ §20.1.2, for counting inpatient days during a leave of absence.)

“A conservative approach to retain the presumption for limitation of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage. Such a notice is not appropriate. If a SNF determines that covered care is no longer needed, the situation does not change whether the patient actually leaves the facility or not.”

Embrace the Midnight Rule/24-Hour Rule

Kris Mastrangelo, president at Harmony Healthcare International (HHI) in Topsfield, Massachusetts, says that the company has received many questions about how to navigate would-be-Cinderella residents who return after midnight.

“HHI has received a massive amount of calls on patients leaving the facility on a therapeutic pass, with the patient inadvertently staying out past midnight. The discussion is tricky because one must define where the patient is at midnight and if they are gone greater than 24 hours,” she says.

She offers this easy-to-understand guidance on how to keep the rules straight:

• If the resident returns home for more than 24 hours

            o No discharge assessment
            o Still under the same plan of care and evaluate if need new evaluation

• If the resident is gone for more than 24 hours and goes to hospital

            o Discharge assessment
            o New/Revise plan of care
            o New therapy evaluation
            o New PPS schedule
            o If the patient is on leave of absence greater than 24 hours or is actually admitted to the hospital, the patient begins a New Cycle of PPS Assessments and the day of return is day 1. In this case, the skip day rule does not apply.

• Less than 24 hours, regardless of destination, gone at midnight,  equals a skip day.

Wade into MDS Assessments Carefully

The most commonly asked MDS-specific questions are related to therapeutic pass, LOA, and the midnight rule — all of which relate to the tracking data and Assessment Reference Date (ARD), Mastrangelo says.

“Do not complete the face sheet following temporary discharges to hospitals or after therapeutic leaves/home,” Mastrangelo says. “If the face sheet was transmitted prior to the hospital stay, and none of the information has changed, a new face sheet is not required. If you identify changes to the face sheet data, you should update it and transmit the revised fact sheet with your next assessment.”

Bonus: You may not need to complete either a discharge or re-entry tracking form. If the resident leaves the facility temporarily for a visit home (or for another therapeutic or social reason or outing), you don’t need to complete either form, Mastrangelo says.

However, if the resident goes to the hospital while out of your facility — and spends fewer than 24 hours there, as an outpatient or on an observational stay, or admitted for acute care— then a discharge tracking form must be completed within seven days, she says.

Note: “The ARD is not altered if the beneficiary is out of the facility for a temporary leave of absence during part of the observation. In this case, the facility may include services furnished during the beneficiary’s temporary absence (when permitted under MDS coding guidelines  — see Chapter 3) but may not extend the observation period,” Mastrangelo says.

If the resident leaves the facility temporarily during the observation period for therapeutic leave or a home visit, you cannot adjust the observation period, she says.

Example: “The ARD is set at Day 14, and there is a two-day temporary leave during the observation period, the two leave days are still considered part of the observation period. When collecting assessment information, you may use data from the time of the LOA as long as the particular MDS item allows you,” Mastrangelo explains.

If a resident leaves the skilled nursing facility at 6:00 p.m. on Wednesday, day 27 of the resident’s stay, and returns to the SNF at 9:00 a.m. the next morning — without a hospital admission  — then Wednesday becomes a nonbillable LOA day and Thursday becomes day 27 of the resident’s Medicare schedule, Mastrangelo says.

Important: “This procedure applies to all assessments, regardless of whether or not they are being  completed for clinical or payment purposes,” she says.