Nurse assessment coordinators (NACs) new to the job often receive guidance from a mentor during their first two weeks in the role. That mentor might lead the new NAC step by step through all the functions necessary to manage the resident assessment instrument (RAI) process. Ideally, the NAC would continue to receive guidance and orientation for longer than two weeks, but at some point, the mentor must move on. When new NACs are on their own, wondering where to start, some task organization can help to bring structure. Although each facility may have its own set of tasks and duties the NAC must perform, there are a core set of tasks common to the role across many facilities. By helping the new NAC to manage the RAI process, the facility can avoid mistakes that could prove costly. This article will discuss the most common tasks that NACs must perform daily and weekly for success in their role.
The NAC’s duties do not consist of MDS completion alone. To ensure that the RAI process continues smoothly, many more daily tasks must occur.
Schedule Daily Meetings
Many facilities utilize some type of daily meeting to review events scheduled for the day, such as a new admission, planned discharge, or a local choir group coming in to sing for the residents. Additionally, the team may discuss clinical changes, review skilled services, and touch base with department leadership. The NAC can glean valuable information from these meetings. For example, discussion of clinical changes can help the NAC to determine the need to observe for a potential Significant Change in Status Assessment (SCSA).
Review Progress Notes
By reviewing the interdisciplinary progress notes daily, the NAC can more readily identify residents exhibiting clinical changes. These changes may also trigger the need for additional interventions, such as a referral to therapy or the dietitian. For the NAC who also acts as the Medicare case manager, this review can also help to determine if daily skilled needs are being met and whether an interim payment assessment (IPA) would be prudent.
Review Census Changes
Most facilities utilize the electronic health record (EHR) to track census changes, while others may use either manual tracking or tracking in another software program. It is essential for the NAC to monitor census changes because the RAI process includes several tasks related to admission and readmission. For example, all new entries into the facility require, at a minimum, the completion of an Entry Tracking form. Any residents readmitted after a discharge return anticipated or discharge return not anticipated also require an Entry Tracking form. Assessment reference dates (ARDs) must be set for Admission assessments for any resident who resides in the building for 14 days or more. Also, new Medicare Part A residents require an ARD between days 1 and 8 of the Medicare stay for a 5-Day PPS assessment. Readmissions may trigger an SCSA. Only by tracking census changes can the NAC ensure timely completion of these admission and readmission tasks.
Additionally, other census items are often relevant to the NAC. A discharge (DC) or death census change also affects the RAI process. A death in facility tracking form must be completed for any residents who expire in the facility or while on a leave of absence (LOA). (Note: A death while on an LOA may not reflect directly as a death in the facility in the EHR census.)
Furthermore, the NAC must set ARDs for all three types of discharges. The first two types of discharges are the OBRA discharge return anticipated and discharge return not anticipated. The NAC must also identify if the discharge was planned or unplanned. Planned discharges should have an MDS assessment scheduled prior to the actual date of discharge to allow the interdisciplinary team (IDT) to complete the scripted interviews. The third type of discharge is the Part A PPS discharge assessment. The ARD for this assessment may be combined with the OBRA discharge if the discharge date is the day of or the day after the last covered Medicare date. When a change in payer occurs, the census report should indicate the change so the NAC can determine if a standalone Part A PPS discharge assessment is needed for the residents who have ended Medicare coverage but did not leave the building.
When determining the need to complete a Part A PPS discharge assessment, it is imperative that the NAC understand the interrupted stay process. More information on the interrupted stay can be found in AAPACN’s Interrupted Stay Policy FAQs and Resources.
MDS Scheduling and Preparation
Before the NAC and the IDT can complete an MDS, the assessment must have an ARD. This ARD establishes the common look-back period for the assessment. It is important for the NAC to set the ARDs and communicate them to the IDT with enough time for the team to schedule their individual assessments, obtain necessary documentation, and schedule the scripted resident interviews that must be completed during the look-back period (preferably the day of or the day before the ARD in most cases).
Certain tasks that need to be completed during the MDS look-back period can be delegated to other members of the team. For example, the resident’s weight must be documented within 30 days of the ARD. The NAC can delegate this task to the CNA to ensure that a weight is obtained before the ARD. Another example is ensuring physician documentation supports diagnoses in the past 60 days. The NAC can delegate to the charge nurse the task of querying the physician to ensure all relevant diagnoses are properly documented in the medical record. Other examples of documentation that would be needed during the look-back period could include CNA documentation (e.g., ADLs, functional status, continence), scheduled facility-specific assessments (e.g., fall risk, skin risk, wandering risk, nutritional), therapy logs, and therapy documentation.
In addition to ensuring the ARDs are set timely, the MDS and RAI process must also be completed timely. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) has a very specific set of timeframes for completion of assessments and tracking forms.
- An Entry Tracking form must be completed no later than seven days after the entry date.
- An Admission assessment must be completed by day 14 of the stay.
- A Quarterly assessment must be completed no later than 14 days after the ARD.
The RAI User’s Manual provides a detailed OBRA assessment summary table on pages 2-16 through 2-18 and a similar table for the PPS assessments on page 2-45.
If these timeframes are not met, the facility could receive survey deficiencies and even lose revenue in some case-mix states or with Medicare Advantage plans. Because these assessments are required to meet federal regulations, the NAC must set aside time for their completion. The 2021 AAPACN NAC Work Time Study and Salary Report showed an average of 87 minutes to complete an OBRA comprehensive assessment, 46 minutes for care area assessments (CAAs), and 54 minutes for care plan development. These times are averages and will vary based on NAC experience and the resident’s clinical complexity. It is important to communicate any workload concerns and barriers to achieving deadlines with the director of nursing services and/or administrator.
Schedule Weekly Meetings
The NAC is an important member of the IDT and may be asked to attend or even run certain weekly meetings, such as resident care plan conferences, Medicare meetings, and risk meetings. It is important to plan enough time during the week to prepare for these meetings. More information on Medicare meetings can be found in AAPACN’s Medicare Basic Training on-demand workshop.
Completing the MDS schedule for OBRA and Medicare PPS assessments can be a daunting task. Scheduling MDS assessments must include more than just printing the automated scheduler from the EHR. The NAC must fine-tune the schedule to streamline the workflow, adjust for state case-mix concerns, and account for holidays or vacations. Each NAC may have a different method for creating the schedule of assessments to be completed. Some NACs may complete the schedule on a weekly basis so that additions can be made, such as new admissions, SCSAs, or discharge assessments. Others may prefer to take a monthly approach. Regardless of how the schedule is developed, it must be communicated to the IDT with enough time to complete the required tasks. These schedules may also be used to schedule the resident care plan conferences. AAPACN has provided an interactive and static OBRA scheduling tool to assist the NAC with keeping the dates on track, which can be found here.
Transmission of Assessments and Tracking Forms
Once the MDS and tracking forms are completed, they must be transmitted to the Quality Improvement and Evaluation Assessment Submission and Processing (QIES ASAP) system. Information on the QIES ASAP system can be found at the QIES Technical Support Office (QTSO) website. As with MDS completion, there are regulatory timeframes associated with this transmission—see the table from pages 2-16 to 2-18 and 2-45 of the RAI User’s Manual.
Here too, failing to follow submission timelines could subject the facility to survey deficiencies and reimbursement issues. This national repository has many uses, including matching PPS assessments with Medicare claims, Quality Measure reporting, determining SNF Quality Reporting Program (QRP) stays and contributing to the calculation of the staffing domain for the Five-Star Quality Rating System. All of these uses rely on timely submission to the QIES ASAP system. (More information on QMs, SNF QRP, and Five-Star can be found in AAPACN’s Quality Measure Survival Guide and Five-Star QM’s On-Demand Workshop).
In addition to the transmission, the NAC must also be aware of the results of the transmission. The NAC should review the Final Validation report after each transmission to confirm that the record was accepted. If there are any rejections or warnings, the NAC should research and follow up as needed.
AAPACN has created a SAMPLE Task List for the Nurse Assessment Coordinator (NAC) tool to assist NACs in organizing their daily and weekly work schedules.
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