Certified Medicare and Medicaid long term care facilities must conduct mandatory assessments in accordance with a rigid MDS schedule upon admitting residents, regardless of a resident’s payor or qualification for Medicare or Medicaid. One such tool is the Minimum Data Set (MDS), a standardized assessment conducted by an MDS nurse or coordinator.
An MDS assessment provides a long term care facility with a comprehensive and multidimensional view of a resident’s functional capabilities and existing health problems. It measures and records their physical, psychological, and psychosocial functioning.
Under the previous RUG-IV payment model, facilities were required to conduct scheduled assessments on days five, fourteen, thirty, sixty, and ninety during the Medicare Part A stay. However, since the current PDPM payment model was made effective on October 1st, 2019, the MDS schedule now includes three Prospective Payment System (PPS) MDS 3.0 assessments:
- the Five-Day PPS Assessment
- the Interim Payment Assessment (IPA)
- the PPS Discharge Assessment.
While the Five-Day PPS and the PPS Discharge Assessments are obligatory, the IPA is optional and is only completed after the facility has determined whether the resident has undergone significant clinical changes, triggering a new PPS assessment.
Understanding the MDS Assessment Schedule
Under the current PDPM model, the MDS assessment schedule for skilled nursing facilities must be in accordance with specific guidelines. Teams must assess a resident’s clinical condition by completing a series of MDS 3.0 assessments.
Of course, while MDS assessments apply to all residents in a skilled nursing facility, Medicare reimbursements only apply to those who qualify for Medicare Part A—a premium-free reimbursement—and are exclusively available to seniors age 65 years or older who have paid Medicare taxes for a minimum of ten years.
Seniors can also qualify for Medicare part A without paying premiums if:
- They receive retirement benefits from Social Security or the Railroad Retirement Board
- They are eligible to receive Social Security or Railroad benefits but have yet to file for them
- They were previously employed by the government, and thus, received Medicare reimbursements
Meanwhile, seniors who did not contribute towards Medicare taxes during their employment years, do not qualify for Medicare Part A. Therefore, they must pay for services out of their pocket or through a private healthcare insurance.
What Are PDPM PPS Assessments?
As mentioned earlier, the PPS MDS schedule under the PDPM model involves three assessments:
- Five-Day PPS Assessment: The Five-day Assessment is usually conducted between days one to eight after the resident enters the facility. Medicare payments cover up to 100 days or until the resident is discharged if the time spent in a facility is less than 100 days.
- Interim Payment Assessment (IPA): An IPA Assessment is optional and is triggered at the facility’s discretion. If a facility chooses not to conduct an IPA, Medicare reimbursement is calculated from the Five-Day Assessment for the duration of the resident’s stay. But while the IPA is not mandatory, it is still a valuable tool for facilities to track the resident’s health conditions and whether a higher level of care is needed.
An IPA should be conducted when caregivers notice a significant change in the resident’s health condition that requires a different treatment with higher costs. Similarly, if caregivers believe a lower reimbursement can be applied, they should conduct an IPA.
- PPS Discharge Assessment: A Discharge Assessment is usually conducted under two circumstances, which are: when the Medicare Part A period ends (100 days) but the resident continues to stay in the facility; and when the resident is discharged on the same day or within 24 hours of the end of a Medicare Part A stay. In such cases, the MDS nurse can conduct an OBRA Discharge Assessment alongside the Medicare Part A PPS Discharge Assessment or combine the two assessments.
While these assessments may differ in the MDS schedule time frame, each assessment must do the following to be in accordance with CMS guidelines:
- Accurately reflect the resident’s status
- Be conducted by an MDS nurse or coordinator
- Include direct observation and communication with the resident about the frontline caregivers present during shifts
- Cover the Observation (Look Back) Period, or, the time when the resident’s condition is documented in the MDS assessment via the care plan software
- Exclude codes other than the codes identified in the Observation Period
Failure to comply with these guidelines or timeframes may result in the facility receiving f-tags during a survey. So facilities must be mindful of these requirements to avoid unnecessary problems.
Discover how long term care software can aid your MDS assessments by contacting our industry experts here.
What Is an OBRA Assessment?
An OBRA assessment is another assessment included in the MDS 3.0 series of scheduled assessments for skilled nursing facilities. The OBRA assessment schedule is conducted at admission, quarterly, annually, when a resident’s health status experiences a significant change, and when the facility identifies a significant error in a previous assessment.
An OBRA assessment is also conducted for new residents upon admission or for returning residents. They must be:
- Completed alongside CAAs
- Completed within fourteen days of the date of admission
- Conducted during the last day of the Observation Period, as the Assessment Reference Date (ARD) should be no later than day fourteen.
Further, both the MDS completion date and the CAA(s) completion date should be conducted no later than day fourteen and the Care Plan completion date must be no later than seven calendar days after the CAA(s) completion date.
Due to the time frame when OBRA assessments take place, it is common for the OBRA and Medicare MDS schedule assessments to overlap. In such cases, an MDS nurse can combine and conduct both assessments to satisfy assessment requirements. For this reason, the MDS nurse must understand the requirements for both assessments to avoid medical errors, unnecessary duplication of resident data, and inefficient workflow processes.
MDS nurses who want to learn more about these topics can turn to published resources from the CMS like Chapter Two: The Assessment Schedule for the RAI (Resident Assessment Inventory), which details the mandated clinical and Medicare assessment instructions for skilled nursing facilities.
Finally, while an MDS nurse meticulously conducts and enters the clinical results for these assessments, they must also ensure the facility receives accurate PDPM reimbursements. To comply with the MDS assessment schedule and PDPM requirements, an MDS nurse can use long term care software that comes with MDS charting examples.
They can also utilize applications like Experience Care’s upcoming PDPM Maximizer, which automatically reviews transfer paperwork to suggest missed diagnoses, saving MDS nurses time and potentially increasing the facility’s reimbursements by thousands of dollars.
The Value of an MDS Schedule and MDS Nurse
Long term care facilities are places where seniors go for a higher quality of life, whether by improving their physical activity, mental capacity, or psycho-social well-being. Facilities must identify their needs and level of assistance through an MDS assessment to ensure residents maintain the highest level of independence and dignity during their stay. For this reason, the MDS schedule and assessment is an invaluable tool for long term care facilities.
The MDS schedule identifies a resident’s level of function and the existing health conditions that need to be monitored. Studies show that an MDS coordinator is crucial in coordinating care processes, creating personalized resident care plans, and assessing the quality of care to determine accurate PDPM reimbursements. So as the facility’s PDPM experts, MDS coordinators need the support of leadership.
Teams must also implement effective nursing home software that includes automatic processes for PDPM. Failure to do so impacts the completion of MDS documentation, ultimately affecting the facility’s PDPM reimbursements and even nurse retention. This is often the case for organizations that utilize software designed for acute care in their long term care settings as well. As seen above, calculating PDPM is a complicated process, and improving the process of doing so is sure to pay for itself.
For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast.
- How to Treat a Kennedy Ulcer - September 19, 2023
- How Caregivers and Seniors Can Prepare for Hurricane Season - September 7, 2023
- 6 Ways to Integrate Dementia ICD 10 Codes to Enhance Care - September 5, 2023