MDS Alert

Published on Thu Aug 06, 2009 PDF

Defuse the confusion about this OBRA-required MDS assessment.

True or false? You should definitely do a significant change in status assessment if a resident declines in two or more areas.

Unfortunately, the answer isn't so cut and dry. The RAI User's Manual does, however, provide some parameters for when to do an SCSA, which is a comprehensive assessment requiring RAPs and care planning. Keeping those guideposts in mind, you can steer clear of survey land mines and make sure payment keeps pace with a resident's resource requirements and acuity level.

Nail down the basics: The RAI User's Manual defines a significant change as a decline or improvement in a resident's status that isn't selflimiting. The change impacts more than one area of the resident's health status -- and requires interdisciplinary review and/or revision of the care plan.

"Generally, if the condition has not resolved within approximately two weeks, staff should begin a comprehensive RAI assessment. This time frame is not meant to be prescriptive,but rather should be driven by clinical  judgment and the resident's needs," the manual instructs.

Also: You must complete the SCSA (VB2) by the end of the 14th calendar day "following determination that a significant change has occurred," according to the manual.

Use the RAI User's Manual guidelines as a framework for the team to weigh whether to do an SCSA in each individual case. "I tell people that it's a professional decision to determine whether the resident has had a significant change," says Joy Morrow, PhD, RN, a consultant with Hansen Hunter & Co. in Beaverton, Colo. For example, some single events could constitute a significant change, such as development of a pressure ulcer, says Roberta Reed, MSN, RN, a consultant with Plante & Moran Clinical Group in Cleveland, Ohio. That's because, when you look more closely, the pressure ulcer likely reflects a problem in other areas, such as nutrition and/or functional status.

MDS teams sometimes spin their wheels doing unnecessary sig change assessments out of fear of survey repercussions, experts note.

A problem: One facility's MDS team did eight SCSAs on one resident based on his weight going up and down, reports Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. Instead, the team could have figured out why the person's weight was fluctuating, changed the care plan, and moved forward without doing a significant change assessment, says Mines. "A resident with a 5 percent weight loss in 30 days would not generally require a significant change reassessment, unless a second area of decline accompanied it."

Best practice: Regardless of whether you do an SCSA, the care plan should always be up to date in addressing a resident's current status, stresses Reed. And if the care plan is current -- and the team doesn't feel a resident's change in status warrants doing an SCSA -- then document the rationale for your decision in the clinical record, advises Mines. "The team should get input from the physician and even the medical director in such cases, and make sure that documentation is in the medical record," she adds.

On the other hand, "if the interdisciplinary team is unsure about whether a significant change in condition has occurred, it is better to err in favor of completing a significant change assessment," says Reed.

Failure to detect and respond to a significant change until you do the quarterly assessment can nab the facility F tags if surveyors find the change actually occurred weeks before the assessment. Thus, you need monitoring systems that can identify subtle signs of decline in time to turn them around. For example, compare key assessment parameters (see above) on a at least a weekly basis.

Best bet: Identify people at risk for decline and implement restorative before they take a downward turn, advises Cheryl Field, RN, MSN,CRRN, senior healthcare specialist with PointRight Inc. in Lexington, Mass. Field teaches caregivers to identify people vulnerable due to acute illness or even someone with a chronic disease who broke her thumb and is at risk for decline.

"Also look for people in transition -- for example, those coming off physical therapy or occupational therapy, someone who has suffered a significant loss, or starting a new medication that puts them at risk for decline," says Field.

The Medicare payment changes as of the assessment reference date for the SCSA, says Morrow (if the person goes into a different RUG). So "you don't want to drag your feet and realize you should have set the ARD  two weeks ago when the payment would have gone up to reflect the higher utilization of services."

Reminders: "For PPS, if the assessment reference period for the significant change assessment overlaps the time for doing the next [regularly scheduled] assessment, you can combine them," says Reed. You can do an SCSA any time after completion of the admission assessment, states the RAI User's Manual. "A lot of SNF teams that know a patient is going to be there longer than 14 days will combine the admission assessment with the 5-day assessment, which gives you flexibility in doing the 14-day PPS assessment in terms of using grace days for the ARD," Reed says.

Not just for Medicare: If the person is on Medicaid in a case-mix state, the timing of the SCSA can be important, depending on how the state handles its case-mix system. If the state uses an average or  resident-specificrate, the facility should make sure to pick up on significant changes as soon as possible because they will typically increase the RUG scores, says Peter Arbuthnot, a regulatory analyst with American HealthTech in Jackson, Miss.