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Consequences of Poorly Written CAAs

“No one even looks at the care area assessments (CAAs) once they’re done, so why spend so much time on them?” It’s a conundrum that nurse assessment coordinators (NAC) and interdisciplinary team (IDT) members often echo. However, it is also a misconception. Not only do surveyors review the CAAs—as evidenced by numerous Statement of Deficiencies reports (CMS 2567)—but they also provide a valuable tool for interdisciplinary care planning for the IDT. Understanding the survey risks associated with CAAs can help NACs and IDT members understand how to use the CAA process to verify the accuracy of their MDS assessments and develop an effective care plan.

Below, examples drawn from 2021 deficiency data highlight pitfalls of neglecting CAAs.

Survey Risk #1: F-Tag 641, §483.20(g), Accuracy of Assessments

The CAAs frequently appear under F-tag 641 in the Statement of Deficiencies text, which details a facility’s noncompliance and reasons it received the citation. One report underscored the role CAAs play in assessing residents. It stated, “The resident assessment instrument (RAI) for long-term care consists of the minimum data set (MDS), care area assessments (CAAs), and utilization guidelines and care plans…. the documents failed to show how the accuracy of the assessment affected resident care and treatment.”

Another 2567 from 2021 noted that behaviors had been documented in the medical record, but were not coded on the MDS, which resulted in a care area not triggering when it should have. The report stated that a “review of the Care Area Assessment (CAA) summary… revealed no assessment was completed for behavioral symptoms…. MDS assessment was inaccurate regarding behaviors and should have noted the resident had exhibited wandering behaviors during the 7-day look back period.”

Another facility received a citation for failure to identify and address pain and discomfort related to a tooth. Their 2021 Statement of Deficiency noted that “there was no care plan in place related to the tooth and discomfort…. According to the MDS assessment, there were no noted concerns related to the resident’s dental condition, including no dental-cavities, cracks, or loose teeth…. The MDS coordinators… were interviewed on… the completed annual MDS assessment…. [She] stated that she missed it. The concern that the resident’s dental issues being missed on the annual MDS assessment not only affects the MDS but the care area assessment leading to initiation of the resident’s care plans was also discussed at that time.”

Primary Lesson Learned: Even a small inaccuracy on the MDS can have a snowball effect—the longer the inaccuracy goes unnoticed, the bigger the problem can become. Take the examples above—when a NAC did not code behaviors, the behavior care area was not triggered and therefore not assessed; when another NAC missed coding a dental concern, the dental care area was not triggered, not assessed, and no care plan was developed. This problem further escalated as the resident’s dental needs were not timely met, which could have potentially impacted the resident’s quality of life.

Survey Risk #2: F-Tag 636, §483.20(b)(1), Resident Assessment

Often, F-tag 636 is cited for failure to complete the MDS, CAAs, or care plan within the time frames specified by the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. However, the actual content of the assessment of the care area can also be the reason for the citation. A 2567 from the 2021 report stated, “based on interview and document review, the facility failed to ensure resident Care Area Assessments (CAA) included a comprehensive analysis of a resident’s needs, strengths, goals, history, and preferences.” This explanation continued into further detail, “the Pressure Ulcer/Injury CAA… revealed multiple pre-checked areas which included existing pressure ulcer/injury, extrinsic risk factors, [medication] risk factors, and [diagnosis] risk factors. The CAA lacked a comprehensive analysis of the aforementioned pre-populated checkmarks which could have impacted [the resident’s] pressure ulcer/injury status. The CAA further lacked any other considerations which could have affected [the resident’s] pressure ulcer/injury status from resident observation, communication with licensed and non-licensed staff, and resident and/or family input for care planning considerations.”

The CAA process is an interdisciplinary process, but the NAC is responsible for verifying that the CAAs have been completed before signing the completion date at V0200B. Failure to ensure completion can also result in an F-tag 636, as the next facility experienced. The survey noted that both the cognition and behavioral symptom CAAs had been triggered, but the software did not indicate them as completed. “When interviewed… the registered nurse verified she was the RN who completed and signed [the resident’s] MDS… stated she had reviewed [the resident’s] medical record and was unable to find evidence the triggered CAAs had been completed. RN explained the facility’s social services department was responsible to complete those assigned CAAs and added she had once in a while noticed they were not getting done. RN stated she sends e-mails to persons when they need to be completed, however, does not typically follow-back to ensure they get done. RN expressed the facility had not reviewed their processes or done any education to ensure CAAs are completed before the MDS’s are submitted since [the resident’s] MDS was completed, and added it was important to ensure CAAs are being done as they’re part of the whole assessment…. facility’s policy on CAA(s) completion was requested; however, none was received.”

Primary Lesson Learned: The RAI process is a requirement of federal regulation that is heavily monitored, from its timely completion to the quality of the content. The NAC is generally the RN responsible for overseeing this process. But it’s not enough to send a reminder email or simply make sure software lights turn green—the NAC must also monitor the quality of the assessments and provide education and guidance as needed.

Survey Risk #3: F-Tag 656, §483.21(b), Comprehensive Care Plans

The care areas are deeply tied to the care plan, which is also evident in the 2021 deficiency reports for F-tag 656. One facility received this citation because it failed to develop and implement a comprehensive care plan. A resident was cognitively intact and had daily severe pain, but the CAA summary “indicated the pain care area triggered and a pain care plan would be developed…. The MDS Nurse said a pain care plan should have been developed but had not.”

After reviewing many 2567s for F-tag 656 throughout 2021, a trend emerged: facilities had care areas that required a care plan decision to proceed to the care plan, but the facility did not develop a care plan that addressed the care area. While the exact wording varies on each report, it often sounds like this: “The care area assessment summary documented the areas of cognitive loss, visual function, communication, activities of daily living, urinary incontinence, falls, nutritional status, fluid maintenance, dental care, and pressure ulcer would be addressed on the care plan…. The director of nurses reported the care plan should have been completed with all of the areas addressed on the assessment.”

Primary Lesson Learned: The care area process is the critical thinking part of the RAI process. The MDS assessment, in and of itself, is not comprehensive—but once you incorporate critical thought, it becomes a comprehensive assessment. It is critical to use this critical thinking process to develop an individualized, person-centered care plan. In addition, failure to follow through on decisions made during the CAA process can also result in omissions in the care plan or an ineffective care plan.

The Bottom Line: From MDS accuracy, to resident assessment, to the care plan, the CAA process is an essential component that, when poorly done, has the potential to negatively affect quality of care or be detrimental to the resident’s quality of life. However, when the MDS is coded with integrity and the care areas are thoroughly assessed and used to develop the comprehensive care plan, the result can be a holistic approach to resident care that promotes quality outcomes and reduces survey risk. In addition, CAA notes can help move the process from a multidisciplinary approach to care planning to an interdisciplinary approach. When IDT members review team members’ CAA summary notes, they can better understand how problems are interconnected, align goals, and develop more effective care plans.

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