V

acation time!
       We all work so hard during the year, and this is the time of year when most of us take off for vacation. You will hear, “How long will you be gone? Who is taking over? What will we do without the Minimum Data Set (MDS) coordinator?”
       These are questions that must be answered as soon as possible before you go on vacation. Make sure the people who are covering for you know exactly what your systems are; otherwise, you may be faced with a crisis situation when you return, with late MDSs and a pile of work on your desk. Here are some helpful suggestions for planning ahead:
       1. Make a list of the meetings you attend that require the MDS coordinator.
       2. Write down your daily routine and checks and balances for others to see. This step we have written down as part of the job description, so it is more or less permanently kept. It is so that if a person leaves, the start-up time and learning curve for the next person is reduced.
       3. Make sure that you leave explicit instructions on where to find everything, from office supplies to how to transmit. This is also helpful in case you have an emergency and are not at work.
       4. Train others or review the procedure for completing the MDS. There will be less frustration for those covering if they are more familiar with the MDS. This includes where to find information and how to code the MDS.
       5. If possible, have a support person available in case someone has questions.
       You can schedule your quarterlies as many as 80 days early to complete. Complete some annuals early if it makes it easier for when you get back. Routinely scheduled assessments may be scheduled early to stagger dates. Annuals may be completed as early as needed. Although it may make more work for the MDS coordinator at some point, it will make life simpler if there are no or few MDSs to be completed while one is away. This may take some planning, and the team must be aware of the plan.
       Imagine being able to plan your workload so that when you come back, you will not be overloaded with MDSs. Your workload will also be affected by how long will be gone. It is up to the facility to provide back up. Many facilities have 2 people in this position so that one can cover. It is still desirable to lessen the workload of others to make sure that what absolutely needs to get done gets done.
       It is also a good idea to have a policy and procedure manual for systems. Make sure you have this in a conspicuous place so that you will always feel comfortable taking that long-awaited vacation. You should have a seamless system in place so that the facility will survive without you. Set up temporary passwords as needed to be used while you are gone. Remember, passwords are protected information and should not be shared.
       The last thing you want is to worry about anything. Have a great summer!

Questions and Answers

       Question: I have a big problem with finding a certified nursing assistant (CNA) documentation form for Medicare residents. Also I have a big problem with the nurses documenting one thing, but when I talk with the CNA it is a whole different story with same resident. Also, sometimes when you read documentation on the same resident from 2 different nurses you wonder if it is the same resident they are talking about. I would like to find a form that the CNA can fill out during his or her shift, since he or she is the one giving the direct care to resident, to give to the nurse to help her chart correctly. I have had in-services with the nurses, but they continue to chart without getting with the CNA for correct information. I hope you or someone you may know can help me. (licensed practical nurse, Alabama)
       Answer: This is a common problem, and communication is the key. The nursing assistant is, of course, the one who knows the resident the best. I believe the problem lies in what the nurse thinks the resident can do. There are several forms from companies that the nursing assistants can document on, and then the nurses can refer to it at the end of their shift. Continue with in-services as you are doing, and eventually the nurses will begin to pay attention to the nursing assistants.
       Question: I am a new MDS coordinator. Can you help me? I am using the 18 Resident Assessment Protocols (RAPs) for care plans. Is there a better or quicker way to do care plans? We are in the middle of a federal survey. I hope we live through it. Thanks for your help. (nurse, via e-mail)
       Answer: Personally, I have not found a quicker way to go through the process of completing the Resident Assessment Instrument (RAI). The process was set up to assess the resident using the MDS, completing the RAPs, and then completing the process by developing the care plans. Most residents are very complicated and require almost half or more of the RAPs to be completed, which falls mainly on nursing. The best way to fulfill the requirements on the process is to know your resident well so that the information just flows instead of just relying on others’ observations and documentation. As the MDS coordinator, you have the responsibility to complete the full spectrum of information. While it may be time-consuming, you will feel more satisfaction knowing that you have done your job well.
       It is never easy to work during a federal survey. However, most surveyors will interview you, and you should come out fine if you show confidence and know your job and have your systems in place. Everyone makes mistakes; if one is found, you can correct it while the surveyor is there. Take whatever suggestions he or she has, work as a team, and know that you are doing your best.
       Question: Approximately how long do you think it takes to do a full assessment with RAPs and care plans? This includes the time to gather information. I would also like to know how I could be certified in MDS. (nurse, via e-mail)
       Answer: It takes me 2 hours to complete the process on a new admission. First, I gather information over several days and see the resident in different settings (eg, activities, therapy, at meals, resting in bed, etc.). Second, I review the medication and treatment administration records and the activities of daily living (ADL) sheet for documentation and bowel and bladder continence. Then I read the chart. It takes me 30–45 minutes to complete an MDS and 10 minutes to complete an RAP. Then it takes about 10–15 minutes to individualize a pre-printed care plan. So, an MDS may take an hour when there are just a few RAPs, but a more complicated one may take 2 hours to complete, not to mention the time it takes to complete (or update) the care plans. Quarterlies and Medicare Prospective Payment System (PPS) forms take me about 30 minutes to complete and print, plus a few extra minutes to update the care plan. (For information on certification, visit AANAC, the American Association of Nurse Assessment Coordinators, at www.aanac.org.)
       Question: To whom do I go for help when my computer goes haywire? (registered nurse, Arizona)
       Answer: Hopefully, you will have someone who is knowledgeable in your facility and can help you return to your normal pace. Computers do break down, as do printers, monitors, and other peripherals. Make sure you find a resource person who can help you. Many corporations have help desks that will respond to problems and questions.
       Question: My boss wants me to work the floor and take a team at least once a week, and I have to do assessments. What do I do? (licensed practical nurse, New Mexico)
       Answer: Patient care always comes first. However, you might explain your workload to your supervisor so that you are clear on his or her priorities. I would explain how long it takes to complete an assessment and that this needs to be uninterrupted time. Many administrators or directors of nursing (DONs) have lost touch with this type of work, and it is easy for them to pull someone out of the department to work the floor. So in that case, at least the supervisor is aware of the situation if an assessment is late.
       Question: Can you tell me who does what sections? (licensed practical nurse, Utah)
       Answer: There are some obvious answers and some not so obvious. Facility policy is set by the administrator, DON, and MDS coordinator. The social services department typically completes “E” and “F” sections, dietary completes “K” sections, and activities completes “N” sections. There is some overlap in some sections. Some buildings have the nurse complete cognition, and other buildings have social services complete it. Whatever you decide, make sure it is clear so that you are not waiting for information. The nurse can complete all sections, but it is generally good practice to have a team approach to assessing a resident. And remember—it is okay to have more than one person complete a section.
       Question: How can I get the nurses to document information that is required in the MDS? (licensed vocational nurse, Texas)
       Answer: Excellent question. There are forms from several companies that prompt nurses and nurse’s aides to chart information that is required on the MDS. Admission forms are the initial form for information, and many companies have developed their own. Additionally, in-services for nurses who chart in a narrative manner can be prompted to document information.
       Question: Where should I cite my references on the MDS—on the summary sheet or in the RAPs? (registered nurse, California)
       Answer: The MDS manual states, “[R]efer to your documentation from the chart.” So, it does not really matter.
       Question: Our numbers for infection keep going up. What should I do? (registered nurse, Montana)
       Answer: Getting the information from the MDS is highly valuable. At the very least, in-services on washing hands must be given and made mandatory. As the person who codes the information and retrieves reports, you are one of the first persons to note this problem. Make sure it is discussed in quality assurance (QA) meetings, and have someone keep a record to look for clusters and other groupings of infections.
       Question: What do you do about grey areas—that is, areas that you really are not sure how to code something? (licensed practical nurse, Arizona)
       Answer: Answers to certain items can be difficult code accurately. The rule of thumb is to err on the side of most difficult for the resident. Choose situations that illustrate the point. Then, when writing the RAPs, the writer can describe the item and explain why he or she chose to code the section in a certain way.
       Question: I like to capture a higher Resource Utilization Groups (RUG) level for intravenous antibiotics, but I don’t always have the medication record from the hospital. It is very frustrating. What should I do? (registered nurse, Oklahoma)
       Answer: Talk to your admissions or marketing director. Explain that the facility receives a higher reimbursement under Medicare if certain information can be coded into the MDS. Intravenous antibiotics are one of the coded items. Request one week’s worth of medication records. And, you can work with your medical records director to request the information if the resident has already arrived.
       Question: How often should I transmit information to the state? (licensed practical nurse, Georgia)
       Answer: Weekly is a good idea so that information can be updated in the state data bank. Some facilities do, however, transmit monthly, and some facilities transmit twice a week.

Got a Question?

       If you have a question you would like to see addressed in a future "Mastering the MDS" article, e-mail Managing Editor Ryan Dougherty at ryand@hmpcommunications.com.