It’s the “Which came first, the chicken or the egg?” question of the Minimum Data Set (MDS) world: Which do you assess first, B0700 or the MDS scripted interviews? It’s easy to get lost in this question when reviewing the coding instructions for the scripted interviews and steps for assessment for MDS item B0700, Makes self understood. This article will help the interdisciplinary team (IDT) navigate the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) instructions to fully understand the intricate relationship between B0700 and MDS interviews.
Step 1: Understand key concepts and definitions.
Two key concepts that drive the MDS process are the Assessment Reference Date (ARD) and the observation period. The ARD is the endpoint of all observation periods for the MDS assessment. These concepts also signal the MDS team members when the scripted interviews and other supporting assessments or documentation need to be completed. For the MDS scripted interviews and other supporting documentation, if it did not occur during the observation period, it cannot be coded on the MDS. However, the team must also wait until after the ARD to code certain items because an item reflects the entire look-back period. For example, J1550A is coded if the resident has a fever during the 7-day look-back period. If this item was completed before the ARD, it would risk missing documentation within the entire observation period that would have supported coding fever.
The RAI User’s Manual definitions for ARD and for observation period are key for understanding when an item must be assessed for coding on the MDS. These definitions are noted here for reference.
| Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or “look-back”) periods in the MDS assessment process. The facility is required to set the ARD on the MDS Item Set or in the facility software within the required time frame of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and PPS) and varies by assessment type and facility determination. Most of the MDS 3.0 items have a 7-day look-back period. If a resident has an ARD of July 1, 2011, then all pertinent information starting at 12:00 a.m. on June 25th and ending on July 1st at 11:59 p.m. should be included for MDS 3.0 coding. (CMS, 2023, p. 2-9) Observation (Look-Back, Assessment) Period is the time period over which the resident’s condition or status is captured by the MDS assessment. When the resident is first admitted to the nursing home, the RN assessment coordinator and the IDT will set the ARD. For subsequent assessments, the observation period for a particular assessment for a particular resident will be chosen based upon the regulatory requirements concerning timing and the ARDs of previous assessments. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. When completing the MDS, only those occurrences during the look-back period will be captured. In other words, if it did not occur during the look-back period, it is not coded on the MDS. (CMS, 2023, p. 2-14) |
Step 2: Carefully follow the instructions.
The instructions for each MDS scripted interview use similar language that instructs the assessor to “interact with the resident using their preferred language” (CMS, 2023, p. C-1). Thus the team must first assess MDS item A1110 to determine the resident’s preferred language and whether the resident needs or wants an interpreter. The instructions then go on to state, “If the resident needs or requires an interpreter, complete the interview with an interpreter. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards” (CMS, 2023, p. C-1).
The next step is to “determine if the resident is rarely/never understood verbally, in writing, or using another method” (CMS, 2023, p. C-1). If the resident is rarely or never understood, the assessor skips the scripted interview and proceeds to the staff assessment. But how does the assessor know what the RAI User’s Manual means by “rarely/never understood”? To better understand this instruction, the assessor should look at the definition for B0700, Makes self understood, and the coding instructions for rarely or never understood .
| MAKES SELF UNDERSTOOD Able to express or communicate requests, needs, opinions, and to conduct social conversation in their primary language, whether in speech, writing, sign language, gestures, or a combination of these. Deficits in the ability to make one’s self understood (expressive communication deficits) can include reduced voice volume and difficulty in producing sounds, or difficulty in finding the right word, making sentences, writing, and/or gesturing. (CMS, 2023, p. B-7) Code 3, rarely or never understood: if, at best, the resident’s understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet). (CMS, 2023, p. B-8) |
Step 3: Get the timing right.
The MDS cannot be completed in chronological order from section A to Z. The team must recognize when supporting documentation should be finalized, as well as the completion timing for each MDS item. This statement is especially true for the MDS scripted interviews and resident voice items that must be completed during the 7-day observation period and the responses coded directly on the MDS.
In fact, the assessor must consider not only whether the resident was able to complete any of the scripted interviews when coding B0700, but also remember that this information must be coded after the ARD based on look-back period documentation. The RAI User’s Manual clarifies that B0700 “cannot be coded as Rarely/Never Understood if the resident completed any of the resident interviews, as the interviews are conducted during the look-back period for this item and should be factored in when determining the resident’s ability to make self understood during the entire 7-day look-back period” (CMS, 2023, p. B-8). However, the instructions go on to state that, “while B0700 and the resident interview items are not directly dependent upon one another, inconsistencies in coding among these items should be evaluated” (CMS, 2023, p. B-8).
Step 4. Map out the process.
Looking at the overall process and connection between B0700 and the MDS interviews, the interviews must be completed before B0700 is coded. The interviews are completed within the 7-day look-back period, whereas B0700 needs to reflect the resident’s ability to make self understood during the entire 7-day look-back period. Therefore B0700 should not be completed until after the ARD and must consider if the resident was able to make himself or herself understood on any of the scripted interviews.
It’s also important to remember this coding tip: “Attempt to conduct the interview with ALL residents” (CMS, 2023, p. C-2). The team should try to use the scripted interviews with each resident, providing the opportunity for the resident’s voice to be heard during the look-back period. If the resident is deemed to be rarely or never understood during the interview attempts and during the entire look-back period, B0700 should accurately reflect this finding and support when the assessor proceeds to the staff interview.
Reference
Centers for Medicare & Medicaid Services (CMS). (2023). Long-term care facility resident assessment instrument 3.0 user’s manual, version 1.18.11. https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf
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