MDS Alert

Cut through the confusion with this guide and expert advice.

Time flies when you're doing all of those MDSs, which is why you need to strategically manage deadlines before they start managing you.

The good news: The MDS deadlines are actually in alphabetical and numerical order, observes Maureen Wern, CEO of Wern & Associates in Warren, OH. So "you can sequence them in the order in which they occur," she says.

Use the following timeline and key pointers at each step to keep your RAI compliance record on track--and your facility in the black.

1. Admission and setting the assessment reference date: The first date--and one over which you have no control--is the resident's day of admission, notes Wern. For PPS assessments, the next "most significant date is the assessment reference date," which is A3a, says Wern.

The ARD runs all the way through midnight, which means interdisciplinary staff members may miss key RUG drivers or falls and behavioral symptoms if they stop assessing the resident before then, caution MDS experts.

"You have to let the ARD pass to complete the assessment," emphasizes Joel Van Eaton, BSN, RN, CRNAC, reimbursement clinician for Care Centers Management Group in Johnson City, TN.

Remember: You can change the ARD all the way up to the last available grace day for the assessment in order to better capture a resident's RUG drivers so he goes into the RUG with the highest case-mix index, which will pay the most.

The biggest mistake consultant Sheryl Rosenfield, RN, sees "people make in the RAI process is setting the ARD without knowing the resident's clinical issues--and later on, the person's specific care path that would affect RUG payment categories," she says.

Ideally, the team should set an ARD upon the resident's admission or later in the assessment process, advises Rosenfield, who is with Zimmet Health Care Group in Morganville, NJ. But the team should wait until the MDS coordinator or another designated clinical team member validates that that date is the one it should use, she adds.

Real-world practice: Sunshine Terrace Foundation Rehabilitation Center uses a prescreening tool that focuses on capturing extensive services for the nine rehab RUGs. MDS coordinator Inne Taylor, RN, develops a calendar for each Medicare resident noting the person's ARD dates. The team "highlights the days of extensive services provided in the hospital and at the facility so we can see" the best ARDs possible "for both the 5-day assessments and the 14-day assessments," she says.

2. AA9 (dates and signatures of those completing a portion of the assessment): Each MDS team member responsible for a section of the MDS signs at AA9 and includes the date that he or she completed it. Sign AA9 on the date you complete a section and determine it's accurate, emphasizes Marilyn Mines, RN, BC, RAC-C, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. The person signing AA9 is attesting that the "information included is accurate," Mines emphasizes.

If the MDS coordinator completes a section, then she also signs and dates AA9, Mines adds. (For an in-depth look at the implications of the attestation statement, see the October 2006 MDS Alert.)

Example: If the therapist actually did the balance test in the RAI manual, he would sign at AA9 that he completed Section G3. "But sometimes the therapist provides a worksheet showing his input on the resident's balance using a test that isn't the same one on the MDS at Section G3," says Christine Twombly, RN, chief clinical consultant with Reingruber & Company in St. Petersburg, FL. "Or the therapist may give input as to how the resident performs ADLs in therapy. But the nurse would still sign for Section G at AA9 if she compiled and analyzed the data [from multiple sources] to arrive at an accurate coding response."

Watch out for this potential inconsistency: Since AA9 represents the date a person completed a section of the MDS, you wouldn't expect to see that date prior to or on the same date as the ARD (A3a), which runs through midnight. You could, however, complete a few areas in Section AA before the ARD--for example, some of the person's identifying information that shouldn't change, says Mines.

While "it's unusual" to see the dates and signatures at AA9 on the same date, that could happen if the facility truly acts as a team by meeting to share assessment data and complete the sections together, says Wern.

What if someone can't sign AA9 on the day she completed a section? You can appropriately "use the actual date" you sign, says Mines. "But document the reason for the discrepancy in the medical record," she advises. Some facilities print out section AA9 and have staff sign and date the attestation when they complete their section of the MDS, says Mines.

3. R2a and R2b (signature and date RN assessment coordinator signed the MDS as being complete): The nurse signs R2a and dates R2b to certify that all MDS sections have been completed, says Mines. Unlike AA9, R2a and R2b isn't an "attestation that the MDS is accurate"--just that the MDS sections are complete, she adds.

Remember: "An LPN can collect data and sign AA9, but the RN must sign and date R2a and R2b indicating completion of the MDS," says Janet Feldkamp, an attorney in Columbus, OH.

4. VB2 (resident assessment protocols) and care plan decision (VB4) for OBRA-required comprehensive assessments, including admission assessments: For a non-OBRA PPS- only assessment, facilities have the assessment reference date plus 14 days to complete the MDS (R2b). But for an OBRA comprehensive assessment--or a combined PPS and OBRA comprehensive assessment--you have to do the resident assessment protocols (RAPs) and care plan. VB2 is the date that you complete the RAPs, says Mines. The care plan completion date is VB4. You have seven days after completing the RAPs  to complete the care plan. 

Correct this common misperception: Some people think the RAI process allows a 21-day timeline from "admission to finish the care plan," says Mines. But the rule says you must complete the MDS and RAPs within 14 days of admission, she says.
"And the care plan must be completed within seven days of completing the RAP portion of the comprehensive assessment."

Thus, if the R2b date is on day 8, and the completion of the RAPs (VB2) on day 12, then the care plan decision (VB4) must be by day 19--seven days after the team completes the RAPs, says Mines.