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Care Area Assessments: Don’t Let CAAs Be the Missing Link in the RAI Process

The care area assessment (CAA) process sometimes mistakenly gets lumped under the “required but not critical to resident care” label of regulatory paperwork. While working the CAAs is indeed a mandatory step in the Resident Assessment Instrument (RAI) process for OBRA comprehensive MDS assessments, it’s also a crucial link between the MDS assessment and the care plan, says Carol Hill, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL.

“Essentially, the CAAs take the guesswork out of care planning through the structured application of critical thinking,” explains Hill. In the CAA process, care area triggers (CATs), which are specific MDS items that are coded in a certain way (either alone or in combination with other items), can identify up to 20 care areas for review. These care areas are listed in the following chart excerpted from page 4-3 in chapter 4, “CAA Process and Care Planning,” of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual:

1. Delirium2. Cognitive Loss/Dementia
3. Visual Function4. Communication
5. Activity of Daily Living (ADL) Functional / Rehabilitation Potential6. Urinary Incontinence and Indwelling Catheter
7. Psychosocial Well-Being8. Mood State
9. Behavioral Symptoms10. Activities
11. Falls12. Nutritional Status
13. Feeding Tubes14. Dehydration/Fluid Maintenance
15. Dental Care16. Pressure Ulcer/Injury
17. Psychotropic Medication Use18. Physical Restraints
19. Pain20. Return to Community Referral

The Centers for Medicare & Medicaid Services (CMS) doesn’t mandate a specific tool for analyzing triggered care areas, says Hill. “Providers can choose to use the Review of Indicators tools found in Appendix C, ‘CAA Resources,’ of the RAI User’s Manual—and many do use them because the tools are incorporated as CAA worksheets into their MDS software systems,” she notes. “However, CMS only requires that providers find and use a research-based, validated tool.”

Why the CAAs matter

A CAA tool based on current standards of clinical practice provides the framework for doing the evidence-based analysis that needs to occur between assessment and care planning, says Hill. “If your interdisciplinary team follows through and uses a CAA tool as it’s meant to be used, you will be guided to review the issues and concerns that experts in that field determined are important to review to obtain a full picture of that care area for the resident. If you don’t fully invest in the CAA process, you could miss out on some problems or issues that you need to focus on for that particular resident.”

In addition, a thorough CAA process ensures that no two CAAs are exactly the same, says Hill. “Therefore, if you build your care plan from those CAAs, no two care plans will be the same either. Care plans will be more person-centered and more individualized—not the cookie-cutter care plans that serve as red flags to surveyors, lawyers, and medical reviewers.

“The CAA process also helps the interdisciplinary team focus on the resident’s problems, strengths, needs, and risk factors, which in turn helps to develop a more individualized, person-centered care plan,” adds Hill. “If staff follow that care plan developed through the CAA process, your team will be better able to meet the needs of that resident.”

The following steps can help nurse assessment coordinators (NACs) ensure that a strong CAA process is in place:

Identify the facility’s CAA process

Given how heavy staff turnover is in many facilities, it’s a good time to review what CAA process the interdisciplinary team (IDT) should be using, suggests Linda Winston, RN, MSN, BS, QCP-MT, DNS-MT, RAC-CT, a nurse consultant based in Norwich, NY.

Questions to ask about the CAA process include the following, according to Winston:

– What evidence-based tool(s) will the facility use for the CAA process?
– What are the specific documentation requirements related to using that tool?
– Which team member is responsible for what CAAs?
– What kind of training is in place for team members:
* In the facility’s specific CAA process?
* In the core fundamentals of the CAA process, including what the CATs are, how to do
root-cause analysis, and how to draw conclusions from a deep-dive investigation?
– What communication system is in place to ensure communication:
* Between the NAC and IDT members?
* Between IDT members and residents or families?
* Between IDT members themselves?
– How will the NAC and/or other auditors monitor CAA documentation or staff performance
supporting that the process has been completed?

An important part of reviewing the CAA process is identifying the NAC’s authority level, suggests Winston. “Communication between the NAC and the director of nursing services (DNS) is key. Likewise, the communication between the NAC and the IDT members involved in the CAA process is key. Therefore, the NAC must have the authority to communicate information to these IDT members.”

The NAC has to be supported by the administrator, the DNS, and the medical director to ensure that that CAA process is implemented as planned, adds Winston. “Not only do you need the authority to work with IDT members, you should have the appropriate time, resources, and authority to lead the CAA process—in addition to your other responsibilities related to completing the RAI process. For example, if your role includes educating IDT members and auditing the CAA process, you need the support of the leadership team to do that.”

Know the attributes of a good CAA

The CAA process should do more than look for the root cause(s) of the problem or issue identified via a triggered care area, says Donna Adendorff, BA, LNHA, RAC-MT, vice president of skilled nursing center operations at Turenne and Associates Healthcare in Montgomery, AL, and a research and development consultant for the Compliance Store. “A good CAA also addresses the contributing factors that may increase the need for care planning, the risk factors related to that triggered care area, the resident’s strengths and weaknesses, and resident or family input.”

Having all of this information helps IDT members make an informed decision about whether the identified problem or issue needs to be care planned, points out Adendorff. “In addition, the CAA should identify any further interventions that are needed to meet the resident’s needs, such as referrals to outside entities.”

A good CAA will be reflective of the resident’s current state, adds Winston. “Done well, a CAA will tell the story of the resident’s clinical, psychosocial, emotional, and physical picture in that care area. You will be able to see how the data collected on the MDS gets moved into appropriate person-centered interventions on the care plan.”

Break open the books

Many IDT members who are responsible for CAAs have never received specific training on how to use the CAA process and how to complete the tool or worksheet, says Hill. “When I talk to staff members who aren’t following their facility’s CAA process, I often hear, ‘No one ever told me that.’ You need to provide team members with the education and training to work the CAAs appropriately. If all they’ve been told is, ‘You’re responsible for this CAA. Here is the worksheet to fill out,’ they will not understand what is needed in a good CAA.”

“NACs should go back and review chapter 4 of the RAI User’s Manual,” suggests Adendorff. “You can use that as the basis for educating team members on what content the CAAs need to include.”

It’s also important to train IDT members on how to communicate and work together on their assigned care areas, stresses Winston. “For example, if one IDT member is looking at the resident’s cognition status as part of the ADL Functional/Rehabilitation Potential care area, they need to know to consider, ‘How does that cognition status affect other care areas besides the one I’m responsible for? What do I need to discuss with other team members?’”

Monitor routinely: Watch for these common problems

“Education is often the key to success, but it doesn’t work alone,” suggests Winston. “Once the team members have been educated on the CAA process, you then need to audit and monitor the process on a routine basis to ensure compliance.”

Here are some areas to review:

* Miscoded CATs. NACs should ensure that CAT triggers are audited for coding accuracy to ensure that they triggered appropriately—without duplicating audits, suggests Winston. “Does the documentation in the medical record support the MDS items being coded the way they were coded?”

* Failure to check all of the applicable checkboxes. “When IDT members use Appendix C-based CAA worksheets in the MDS software, they often believe that the software pulls anything that needs to be checked into the checkboxes,” says Hill. “However, most software systems only check items that can be pulled from MDS coding. MDS-based items in the Review of Indicators are identified by an MDS item number in parentheses. You have to manually check anything that pertains to the resident that comes from other documentation sources.”

For example, in the Urinary Incontinence and Indwelling Catheter care area, the software will check the box for neurogenic bladder if that diagnosis is coded in I1550. However, if the resident has laboratory tests that indicate high serum calcium, high blood glucose, low B12, or high blood urea nitrogen (BUN) or creatinine, each of those tests that apply to that resident would need to be manually checked.

“If the IDT member who is responsible for that CAA is not reviewing the checkbox indicators and adding in the information that doesn’t come from the MDS, you could be missing out on issues that need to be incorporated into the plan of care,” points out Hill.

Note: Even with a fully integrated electronic medical record (EMR) that pulls information from outside the MDS into the CAAs, team members would want to review all of the checkbox indicators to ensure that no documentation is missing from the EMR.

* Writing the care plan in the CAAs. “Some IDT members mistakenly believe that the CAAs are just a place to restate everything that will be put on the care plan,” says Hill. “But the care plan comes from the CAAs. First, the CATs pull information from the MDS to tell you where to focus a little closer for that specific resident in the CAAs. Then, the CAAs tell you where to focus even more closely for that resident in regard to the care plan.”

Each step should narrow the interdisciplinary team’s focus, says Hill. “If you put on your investigative cap and dig down deep in the CAA process to make sure that you have captured everything that is needed for that particular care area, you will understand what really needs to be care planned—and have the information necessary to fully develop that care plan.”

* Cutting and pasting CAA summaries.“When IDT members feel that CAAs are redundant and they are ‘saying the same thing over and over,’ sometimes they cut and paste summaries from one CAA to the next,” says Hill. “For example, if a resident triggers for the Communication care area and the team member thinks they have written a good summary for that CAA, they may cut and paste that summary into the Visual Function care area, which also triggered.”

CMS acknowledges that certain CATs interrelate and could be combined for CAA analysis and care planning, notes Hill. “However, while CAAs sometimes look at the same issues, they approach those issues from different perspectives. Combining CAAs isn’t a cut-and-paste job. Rather, it’s the collective review of each triggered area. CAA summaries should reflect that. If you’ve worked the CAA process the right way, you shouldn’t be saying the same thing over and over.”

* Blanks in the documentation. “Whatever CAA tool you use, any blank sections should be an automatic red flag,” says Winston. “For example, if you have an item checked in the checkbox section of an Appendix C Review of Indicators tool, there shouldn’t be a blank in the corresponding section of the Supporting Documentation column. You want to be sure there is good supporting documentation identified for each checked item.”

* Not linking the care plan back to the CAAs. “If the outcome of the CAA process was to proceed with care planning the triggered care area, there should be a clear link between the care plan and the problems, risk factors, strengths, and needs that you identified in the CAA,” says Hill.

“For example, if you identified problems with bed mobility in the CAAs, how is that addressed in the resident’s care plan? Or if the resident was identified as incontinent in the CAAs, how is that addressed in their care plan?” she explains. “If you don’t see those links between the CAAs and the care plan, there is a disconnect that needs to be addressed so that you meet the needs of that resident and hopefully have better outcomes.”

Additional Resources            
Two resources from AAPACN may provide assistance on the care planning side of the RAI process:  
AAPACN’s §483.21 Comprehensive Person-Centered Care Planning Cheat Sheet offers a quick overview of the required components of the care plan, starting with the baseline care plan and going through discharge.  
AAPACN’s Comprehensive Person-Centered Care Plan Audit tool double-checks that the necessary components of a care plan have been addressed.

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