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ear Mabel: Can you explain the connection, if any, between the Minimum Data Set (MDS) and the care plan?” (registered nurse, Arizona)
       Answer: The care plan should flow directly from the MDS. We like to think of it in terms of the nursing process: assess, plan, implement, and evaluate. The MDS covers the assessment part of that process. Through the MDS, areas of concern should be identified and further evaluated. If the MDS being completed is a long form, in other words an annual, significant change in status, or an admission assessment, the Resident Assessment Protocols (RAPs) should be completed. Through completion of these more in-depth assessments, a thorough review of the triggered condition will occur. When you have completed these RAPs, the care plan should be a snap to complete. The RAPs will not only identify the problem but the specific cause as well. As an example, let’s say a resident triggers the Activities of Daily Living (ADL) RAP. In the course of completing the RAPs, various possible causes of the deficit assessed will be explored. The clinician will perform an in-depth analysis of the cause and effect. Is the deficit related to a cognitive deficit or a physical deficit? Do any of the medications the resident receives have an effect on ADL performance? Can the resident make appropriate decisions regarding clothing choices? Does the resident have the ability to learn? Does the resident have a vision problem that affects ADL performance? All these questions are asked in the RAPs. We like to call completion of the RAPs, “running the RAPs.” So by running the RAPs, you will know how to implement interventions that are most appropriate for the deficit.
       There are some areas that currently do not trigger a RAP. The most common area is pain. If pain is marked on the current MDS 3.0, there is not a corresponding RAP. Thus, it is up to the clinician to realize that marking pain requires a more thorough assessment and care planning based on that assessment. The new MDS, which has been postponed until 2005 at the earliest, will have a trigger for a pain RAP. Infection control will also be a condition linked to a RAP. Do not fall into the trap of thinking that if a condition is not on the MDS or does not trigger a care plan, it is okay to skip a care plan. To skip care planning at the least would be an oversight. We need to care plan regardless of whether a concern is part of the MDS or not. It may also cost you a citation if surveyors find that you failed to care plan.
       When new issues come up, such as the flu, it may be necessary to care plan but unnecessary to do a MDS. On page 2-8 of the Resident Assessment Instrument (RAI) manual, there is an explanation of when a significant change in status assessment (SCSA) condition is required. If a new condition does not last over two weeks, or is self limiting, you may not need to do a MDS assessment. However, you must care plan for needed care and intervene for the resident at all times.
       Completion of a quarterly assessment requires a review of the care plan. You will want to ask yourself, is the care plan complete? Have any of the interventions changed? If so, why? Always be looking for areas of improvement in the delivery of care. We hold care plan conferences along with every MDS assessment. The resident and family (if the resident agrees) are invited to attend, along with representatives from dietary, activities, social services, and nursing to discuss healthcare decisions regarding the resident. If the family or resident attends the conference, we like to ask them the following questions. “Is there anything we can do to make you happier or feel better?” “Are there any areas of concern you feel we have overlooked?” “Are there any issues you would like to bring up?” We address their concerns and care plan any issues that require continued interventions.
       Care planning and the MDS are as connected as sprockets on gears. If one sprocket is missing, the whole thing grinds to a stop. They go hand in hand. That brings us to our next question.
       “Dear Mabel: We have a new admit, and on day 10, he went into congestive heart failure. The doctor ordered all the appropriate meds and care, and the resident was not sent to the hospital. My question is should I have done a SCSA?” (registered nurse, Iowa)
       Answer: A SCSA cannot be done before the initial assessment is completed. The initial assessment is a comprehensive assessment; it includes the triggers and the RAPs. A SCSA is completed after a period of observation to determine if the change is self limiting. The change must affect two or more areas of functioning, such as behaviors that were easily altered and now are not easily altered. You are allowed up to 14 days to observe for this change and its affect on functioning. If it is decided that the change is not self limited, and it affects two or more areas of functioning, then a SCSA must be completed within 14 days of that decision. As the clinician, this decision making is up to you. It is a good idea to make an entry in the resident’s chart about your decision regarding whether or not to do a SCSA and why it was made. Also, if a SCSA is completed, it is a good idea to make a note, perhaps even on the front of the assessment, as to why it was completed. Again, please refer to the RAI manual, page 2-8. Remember it is acceptable to do the admission assessment and then within 14 days complete a SCSA if it is indicated.
       In the world of MDS news, the therapy cap has again been delayed until 2005. As of December 8, 2003, when President Bush signed the Medicare Reform Act, the cap on therapies was lifted. It has been hard to keep up with this issue as it goes back and forth so frequently. Thank heavens the cap is off again, at least for a while. We need therapies in extended care. Since the enactment of Omnibus Budget Reconciliation Act (OBRA) guidelines, we have become accustomed to assisting our residents reach their highest practicable level of functioning. Before OBRA, there was some therapy in extended care but not the level seen in the last few years. Some feel extended care has been taking advantage of these services. However, we feel just the opposite. The MDS has helped us in extended care to see where and how we can intervene to reach the goal of optimizing every resident’s potential. Therapies have been an integral component, opening new avenues for care and offering new hope for increased independence. We need all the therapies—physical, occupational, and speech—working along with dietary and nursing to assist in reaching the goals set for us by the federal government. Now that we have all bought into the new philosophy of extended care, no one wants to go back.
       Centers for Medicare and Medicaid Services (CMS) has released a three-page memorandum concerning “Physician Delegation of Tasks in Skilled Nursing Facilities and Nursing Facilities.” There is a table that has proven helpful in understanding when and how a nurse practitioner or a certified nurse specialist may write orders. The table can be accessed at http://www.cms.hhs.gov/medicaid/survey-cert/sc0408.pdf. Most clinicians we have spoken with find this table to be a great help. Some have even posted it in their office.
       Thomas Scully has resigned as head of CMS. No one we have spoken to about this event feels it will have any impact on the new quality measures (QMs), which were set to be put into practice in January of this year. Mr. Scully stated upon accepting the position that he would only accept for two years. His lobbying was instrumental in the passage of the Medicare Reform Act. As we go to press, we are awaiting the name of his successor. There is also talk that Tommy Thompson, Secretary of Health and Human Services, will be resigning as he also accepted the job on an interim basis only. Both these gentlemen have had a profound effect on healthcare in their short tenures.
       The Office of the Inspector General (OIG) has published an official work plan for 2004. There are 12 areas they will be working on related to extended care. One of these is titled, “Nursing Home Reporting of Minimum Data Set.” This particular report has an expected issue of financial year 2004. The last official report from the OIG on nursing homes was less than favorable. Let’s hope we do better in the future.
       It is a new year, full of challenges and accomplishments. Here is wishing you attain all your goals, personal and professional.
       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.