MDS Alert

Here's how to keep the RUGs on the money.

Time flies when you're busy. But if your MDS team doesn't take steps to accurately code residents' rehab therapy and restorative minutes in Section P, it could undercut or inflate the RUGs, leaving the facility's fiscal and compliance status in shreds.

Cautionary example: MDS nurse Nemcy Cavite Duran, RN, RNAC, has seen instances where coding of rehab minutes at Section P1b is "short two minutes" of the 325 minutes for rehab high.

For example, one resident "actually received 350 minutes rather than 323," as coded on the MDS, says Duran, director of MDS at Dr. William O. Benenson Rehabilitation Pavilion in Flushing, NY.

Give therapists this tool: One of the best ways to improve therapists' accuracy in reporting minutes is to give them a calculator to add up the minutes, advises Roberta Reed, RN, MSN, director of clinical services for Legacy Healthcare, which has facilities in Ohio. If therapy gives the MDS team the days and minutes of therapy on a piece of paper, the MDS nurse should validate the information by checking the therapy logs, advises Reed.

Remember: "Therapy treatment logs must indicate the minutes per day in order for the minutes and correct number of days to be properly included in P1b," advises Marilyn Mines, RN, BC, RAC-C, director of clinical services at FR&R Healthcare Consulting in Deerfield, IL. By reviewing the therapy logs, the MDS coordinator can rest assured that "the minutes and days for each discipline are recorded accurately" -- and that all disciplines (occupational, physical, and speech therapy) are using the same assessment reference date (ARD) as the MDS coordinator, says Mines.

Watch out for this key mistake: In Mines' experience, errors in P1b most often occur because therapy is using an ARD that "best captures the highest rehabilitation RUG category" rather than the ARD noted in A3a of the MDS.

Avoid This Double Whammy

Talk about a costly combination of errors: failure to capture all of a resident's rehab therapy during the lookback and also overlooking an IV, IV med or other extensive service from the hospital or other setting. An audit of 45 MDSs showed a "potential loss of $75,000" related to that type of scenario, where a resident ended up in a lower RUG classification, reports Duran. The minutes were on the rehab therapy log but not accurate on the MDS, she says.

Capture Restorative Nursing in P3

To receive credit for restorative nursing in the RUG realm, the resident has to be coded as receiving two separate restorative programs for at least 15 minutes each six days a week. For example, you can't combine active and passive range of motion and splint/brace assistance at P3a, b and c to come up with a 15-minute interval.

Residents receiving the requisite amount of rehab therapy and restorative will RUG into low rehab. Add an extensive service to the mix during the lookback, and the resident will go into rehab low plus extensive services. Restorative nursing coded at P3 also pays off in Medicaid case-mix states (for details, see the March 2007 MDS Alert).

Overcome this major coding stumbling block: To take credit for restorative services on the MDS, your program has to meet a short list of RAI manual requirements. "States may have specific requirements, as well," says Mines. "For example, Illinois requires an Endurance/Functional Ability Assessment for residents receiving two or more restorative interventions," she notes.

According to the RAI manual, a restorative program must be nurse-driven and include measurable goals and interventions in the resident's care plan and clinical record. Other staff can carry out the restorative activities, however, if the nursing staff supervises them, adds Mines.

For example, at Sunshine Terrace Rehabilitation Foundation Center, restorative CNAs and therapy aides work with residents but the restorative program is "under the direction of the licensed nurses," says Inne Taylor, RN, the MDS coordinator for the facility in Logan, UT.

To back up coding at P3, you need treatment logs that include the minutes of restorative provided each day, advises Mines. You can provide the 15 minutes of restorative across 24 hours ("10 minutes on the day shift plus 5 minutes on the evening shift) ...," states the RAI manual. In fact, "persons with dementia learn skills best through repetition that occurs multiple times per day," adds the manual.

Documentation tips: Mercy Franciscan at Schroder used to "have a hard time" nailing down documentation of the minutes and numbers of days of restorative "because staff were writing it in a separate place," reports Mary Pierson, RN, director of nursing at the facility in Hamilton, OH. But now the staff uses CareTracker, "an electronic charting system," which has increased consistency "in capturing the restorative nursing minutes," she says.

Even if staff use hand-written documentation, they should  "capture the time spent delivering [restorative] interventions on a  universal form," adds Mines,   noting there are various tracking methods available.