How many times have you heard someone say, “That’s Not My Job!”? Most likely you’ve heard this before — you may have even said it yourself!
The thing is, though, when we think about compliance, it is everyone’s job to try to help ensure compliance with therapy documentation and billing is in line. Therapists are required by their state practice act to ensure accurate recording of the care they provide. Medicare requires therapy documentation to ensure accurate reflection of the care we provide is medically necessary and requires the skills of a therapist. The therapist’s compliance list is endless.
But what about the MDS? Whose job is it to ensure the MDS is opened timely, completed timely, and is submitted timely? The Registered Nurse Assessment Coordinator (RNAC) of course is ultimately responsible for the MDS; however, there are many key players who contribute to the data that goes into the MDS. From nurse aides to therapists, everything we enter into the medical record to reflect the actual care of the resident can be used for MDS data collection. There are many item-set rules that we all must follow, but the MDS leader is the RNAC.
“Given the requirements of participation of appropriate health professionals and direct care staff, completion of the RAI is best accomplished by an interdisciplinary team (IDT) that includes nursing home staff with varied clinical backgrounds, including nursing staff and the resident’s physician. Such a team brings their combined experience and knowledge to the table in providing an understanding of the strengths, needs and preferences of a resident to ensure the best possible quality of care and quality of life. It is important to note that even nursing homes that have been granted a RN waiver under 42 CFR 483.30 (c) or (d) must provide a RN to conduct or coordinate the assessment and sign off the assessment as complete.” MDS-30-RAI-Manual-V114-October-2016.pdf
Sure, therapy is responsible for ensuring the number of therapy days and therapy minutes is accurately provided to the RNAC for entry into section O is completed. But why would a facility want therapy to be solely responsible for information in any other section when their time with the resident is significantly lower than their nursing colleagues?
“An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident’s medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident’s actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.” MDS-30-RAI-Manual-V114-October-2016.pdf
When it comes to the MDS, it IS “our job” to timely, thoroughly, and accurately document the care we provide. We are an Interdisciplinary Team working to care for our nation’s sick and most vulnerable folks. We truly would not be caring for residents if we don’t work as a team and accurately document the great care we provide. And ensuring this happens, IS “our job”!