MDS Alert

Question 1: We just realized we missed an annual on a resident in our facility. Should we use today’s date or put it in as the date it was due?

Answer 1: Backdating is never permitted. When an error is found, correct the error using the dates in real time, usually the date the error is found. This will reset the clock for future MDS assessments.

Question 2: Therapy requested that a SOT assessment be completed. I am not sure this is an appropriate thing to do since the resident will be only at an RMB category when the clinical category is HC2. What do I do?

Answer 2: A SOT is only appropriate to complete when the CMI will increase. If no SOT is completed, the reimbursement will continued at HC2. Remember, completing an SOT is optional. Once the SOT is completed, the RUG will change to RMB. Ask the therapy provider to review the case maximization information in the PPS requirements.

Question 3: A resident has a Stage 3 wound to the foot and it is coded on the prior assessment, but I am now working on a new assessment and the Stage 3 wound healed in my look-back period. I know I will code the wound as healed, but would I still code it as a Stage 3 wound since there were days in my look-back period when it was treated before healed?

Answer 3: The answer is in Section M, Steps for Assessment:

“Complete on all residents, including those without a current pressure ulcer. Look-back period for this item is the ARD of the prior assessment. If no prior assessment (i.e., if this is the first OBRA or scheduled PPS assessment), do not complete this item. Skip to M1030.

1. Review medical records to identify whether any pressure ulcers that were noted on the prior MDS assessment have healed by the ARD (A2300) of the current assessment.
2. Identify the deepest anatomical stage (see definition on page M-5) of each healed pressure ulcer.
3. Count the number of healed pressure ulcers for each stage.”

If the pressure ulcer is healed by the ARD, it is considered healed and not indicated as an unhealed pressure ulcer.

Q&A provided by Marilyn Mines, RN, BC, RAC-CT, of FR&R Healthcare Consulting in Deerfield, IL.