AANAC'S pps review: questions & answers from the American Association of Nurse Assessment Coordinators

Nursing Homes, August, 2006

Q: Someone asked a question the other day on the listserv about whether 15 months' worth of MDS assessments must be sent with the resident upon discharge, or if it is necessary to send only the most recent one. The answer was that only the most recent one must be sent. The whole idea of sending the MDS on discharge is a totally new concept to me. We have never sent MDS material. Where does it say we need to do that?

A: See RAI manual, page 1-17, Transfers of Residents: "When transferring a resident, the transferring facility must provide the new facility with necessary medical records, including appropriate MDS assessments, to support the continuity of resident care."

I have requested and received them from many facilities. It really helps with coding Sections B6, Change in Cognitive Status, and G9, Change in ADL Function.

Cindy Kimpe

Cindy.Kimpe@macombcountymi.gov

Martha T. Berry Medical Facility

Mt. Clemens, Michigan

Q: How is it that an MDS that has been projected to be RV secondary to the number of days and minutes delivered resulted in RMX?

A: Every software system is set up to determine the RUG with the highest rate based on the case-mix index (CMI), which represents the relative weight of the staff time needed for the care and services to be provided to the resident. Once the resident classifies into the rehab RUG based on minutes and days delivered, the CMI is then calculated based on time studies done by CMS.

For example:

* RML has an ADL range of 7-14 and a weight of 44.

* RMX has an ADL range of 15-18 and a weight of 47.

* RVL has an ADL score of 7-15 but only has a weight of 46, which as you can see is lower than the RMX weight of 47.

Therefore, the system gives you the RUG for the highest weight-in this case, the RMX. If the resident had 500 minutes of therapy and an ADL score of 16-18, heor she would have been assigned the RVX RUG, as it has a weight of 49/48.

Brooke Evans

bevans@tgstech.com

Technigraphics, Inc.

Wooster, Ohio

Q: I am having trouble finding what I need in the charts to stage wounds. This resident has peripheral vascular disease with two stasis ulcers. I need to know how these wounds were staged by the floor nurse so I can determine how to code it on the MDS, but the floor nurse told me that they don't stage a wound unless it is a decub. What should I do?

A: According to the standard of clinical practice, stasis ulcers are not technically supposed to be staged, but the MDS does require staging. Our nurses write a description of the ulcer based on their assessment, and we fill out the MDS based on the description. It is the same as reverse staging-pressure ulcers should not be reverse staged, but the MDS requires us to do so. We handle this the same way, translating from the nurses' descriptions to MDS coding.

Gale Siegel, RN

Galinshell@aol.com

Daughters of Miriam Center

Clifton, New Jersey

Q: When rehab, which is the only skilled service provided, ends and the resident is remaining in the nursing home, should SNF coverage end on the last treatment day? Or should the resident be monitored for a couple of days to ensure a decline does not begin?

A: The resident must receive a daily skilled service to qualify for Medicare Part A covered services. Unless your resident is in need of a daily skilled service beyond the last day of therapy, you would issue the Generic Notice two days prior to the last day of coverage. If you have been skilling the resident also for nursing reasons, after the last day of therapy you have until day 8, 9, 10 to do an OMRA. In that case, you could possibly keep the resident a couple more days for observation and assessments for nursing between issuing the Generic and discharge if you feel that it is absolutely needed and there is reasonable probability that there could be an exacerbation.

Vicki Trotter, RN, RAC-C, NACC

naccnurse@yahoo.com

Glennville, Georgia

About AANAC

Q: What is AANAC and how do I get my questions answered on the Resident Assessment Instrument/Minimum Data Set (RAI/MDS)?

A: The American Association of Nurse Assessment Coordinators is a nonprofit association of your peers, including all members of the interdisciplinary team dedicated to networking, education, and advocacy on behalf of all clinicians involved in the RAI/MDS process. From our online discussion group each week, we select the best questions and answers our members have raised. The questions and answers are reviewed by a national advisory board of experts in this field, and they are subsequently published in NAC News, AANAC's weekly online newsletter. In addition to our weekly questions and answers, the newsletter contains a variety of timely and accurate information on this process. AANAC also offers certification and other educational information services for clinicians committed to accurate and timely completion of the MDS. For further information on AANAC, call (800) 768-1880 or visit www.aanac.org.

With thanks to Diane Carter, RN, MSN, CS, President and CEO of the American Association of Nurse Assessment Coordinators (AANAC).