Quality Measure IQ Series: The Re-Specified Long-Stay Antipsychotic Measure

Listen to this article Your browser does not support the audio element. For years, nurse assessment coordinators (NACs) managed the long-stay (LS) antipsychotic quality measure largely through section N of the Minimum Data Set (MDS). Accurate 7-day look-back coding was the primary lever that facilities could pull to reflect their …

Crack the Code: P0100, Physical Restraints

Listen to this article Your browser does not support the audio element. Few Minimum Data Set (MDS) items carry as much regulatory weight and ethical considerations as physical restraints. The decision to use any device that restricts a resident’s movement or access to his or her own body must balance …

Q&A: Am I able to code “yes” in item J1400, Prognosis, when the documentation supporting “life expectancy less than six months” is signed by nurse practitioners or physician assistants, or is a physician signature required?

Question: Am I able to code “yes” in item J1400, Prognosis, when the documentation supporting “life expectancy less than six months” is signed by nurse practitioners or physician assistants, or is a physician signature required? Answer from Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: Yes, if allowable by state laws, on …

Q&A: What specialized training is needed to capture respiratory therapy provided by nurses?  

Question: What specialized training is needed to capture respiratory therapy provided by nurses?   Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC:The Glossary of the RAI User’s Manual (Appendix A-22) states this: Respiratory Therapy Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services …

Q&A: When a resident is discharged to the hospital and admitted with a diagnosis of UTI. Does the UTI get coded on the discharge return anticipated MDS? 

Question: When a resident is discharged to the hospital and admitted with a diagnosis of UTI. Does the UTI get coded on the discharge return anticipated MDS?  Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the diagnosis of UTI did not occur until the resident was at the …

Q&A: How do I code the “Will [care area] be addressed in the care plan” question when a resident discharges return not anticipated before the care plan is complete?  

Question: How do I code the “Will [care area] be addressed in the care plan” question when a resident discharges return not anticipated before the care plan is complete?   Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: Federally, if the care plan was not completed because the resident …

CMS: Impact of Combined Assessments on SNF APU for SNF QRP

Impact of Combined Assessments on SNF APU: How Medicare 5-Day and PPS Discharge Combined Assessments Affect Your Facility’s APU Calculation The Centers for Medicare & Medicaid Services (CMS) has released a one-page resource for SNF providers that illustrates how Medicare 5-Day and PPS Discharge combined assessments can impact the APU …

Why Directors of Nursing Services Must Be Well-Versed in PDPM and How to Ensure Documentation Accuracy

Listen to this article Your browser does not support the audio element. In today’s skilled nursing facility (SNF) landscape, the director of nursing services (DNS) is critical not only in overseeing resident care but also in supporting the organization’s financial stability and regulatory compliance. Both goals require a strong understanding …

Q&A: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer?

Question: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: A Significant Change in Status Assessment is required if there are two or more areas of decline or improvement that will not resolve on its own …

Q&A: If a Discharge – return not anticipated was completed for a resident discharge against medical advice (AMA), and he returned less than 30 days later, is a new OBRA Admission assessment required?

Question: If a Discharge – return not anticipated was completed for a resident discharge against medical advice (AMA), and he returned less than 30 days later, is a new OBRA Admission assessment required? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: When the OBRA discharge is named “Return not anticipated” …