CAA Considerations with Oct. 1, 2023 MDS Updates

The draft Long-Term Care Resident Assessment Instrument (RAI) 3.0 User’s Manual v1.18.11, released in early April, presents revised care area triggers (CATs) in chapter 4 and care area assessment (CAA) worksheets in appendix C. To prepare for the implementation of the RAI changes coming this October, nurse assessment coordinators (NACs) …

Restorative and Therapy: Collaborate for Successful Outcomes

Restorative nursing programs are effective interventions to maintain or improve a resident’s independence in tasks of daily living. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, on page O-42, “Restorative nursing program refers to nursing interventions that promote the resident’s ability to adapt and adjust …

How NACs Can Support Administrative Level of Care Presumption During Medical Review

When a Medicare beneficiary is admitted to a skilled nursing facility (SNF), there are specific requirements that the resident must meet for the facility to bill Medicare for the services provided. The physician must certify that the skilled care in the SNF is necessary; the resident must have Medicare benefit …

NACs Empowered: Tips to Optimize the Resident Interview for MDS Coding

The nurse assessment coordinator (NAC) is responsible for coordinating the completion of the MDS assessment, a process which depends on the interdisciplinary team (IDT) supplying documentation to support MDS coding. While the IDT’s role in generating this documentation is crucial, the NAC can bolster their efforts by utilizing observation and …

Final Step of MDS Management: The Final Validation Report

When an MDS has been signed as complete, grouped into a batch, and submitted to the national repository, the nurse assessment coordinator (NAC) still is not yet done with managing that assessment. The last crucial step in the process is validating that the assessment was accepted in the database without …

How to Speak the Same Language for Section K Coding: NACs and SLPs

When a nurse assessment coordinator (NAC) reviews the speech language pathologist (SLP) evaluation notes and encounters the term globus sensation, he or she may not even consider that the phrase could indicate a potential swallowing problem. While the NAC and SLPoften work toward the same goals of identifying possible swallowing …

Section G: Scheduled for Retirement October 2023

The Activities of Daily Living (ADLs) in section G of the MDS are interwoven throughout the Care Area Assessments (CAAs), Quality Measures (QMs), and some state Medicaid reimbursement systems—and have been for years. Yet CMS took nurse assessment coordinators (NACs) by surprise when the draft MDS item sets released in …

Don’t Shortcut the CAAs

Clinical education teaches nurses a process of problem identification. Encompassing assessment, nursing diagnosis, planning, implementation, and evaluation, it is often just called the nursing process. Many nurse assessment coordinators (NACs) may also recognize that the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual mirrors the nursing process in …

Tips to Achieve Supporting Documentation: Get the Information NACs Need to Code the MDS

Completing the MDS assessment requires documentation in the medical record to support nearly every item’s coding. When supporting documentation is in place, the MDS assessment process can be smooth and efficient. If it is not, the nurse assessment coordinator (NAC) may have to spend hours combing through a chart trying …