MDS Alert

Published on Thu Apr 04, 2019 PDF

Question: One of my residents has improved mobility and no longer needs extensive assistance for bed mobility or toileting, as he can function with limited assistance from staff on those two activities of daily living (ADLs). He still requires extensive assistance for personal hygiene. Would I complete a Significant Change in Status Assessment (SCSA)?

Ohio Subscriber

Answer: Yes, whenever a resident exhibits a change in two or more ADLs, you are required to complete a SCSA, per the RAI Manual, on page 2-22:

“A ‘significant change’ is a major decline or improvement in a resident’s status that:

1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self- limiting”;
2. Impacts more than one area of the resident’s health status; and
3. Requires interdisciplinary review and/or revision of the care plan.

“A significant change differs from a significant error because it reflects an actual significant change in the resident’s health status and NOT incorrect coding of the MDS. A significant change may require referral for a Preadmission Screening and Resident Review (PASRR) evaluation if a mental illness, intellectual disability (ID), or related condition is present or is suspected to be present.”

Note: If you or the interdisciplinary team decides that a resident meets the requirements for a significant change, the assessment reference date (ARD) would be 14 calendar days after determination that significant change in resident’s status occurred (determination date + 14 calendar days).