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MDS and CAAs: The Journey to Great Care. Amy Ruedinger , RN RAC-CT Pinnacle Innovative Healthcare Solutions. Objectives. Analyze recent updates to the RAI manual and the Medicare benefits manual Updates Potential financial impact of the recent updates to the RAI process

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Mds and caas the journey to great care

MDS and CAAs: The Journey to Great Care

Amy Ruedinger, RN RAC-CTPinnacle Innovative Healthcare Solutions


  • Analyze recent updates to the RAI manual and the Medicare benefits manual

    • Updates

    • Potential financial impact of the recent updates to the RAI process

    • Tips for implementation of RAI changes and updates

  • Other Updates and concerns

  • Evaluate the components of root cause analysis as it pertains to overall documentation and the CAAs process

  • Gain tips to promote effective documentation

  • Examine the connection between MDS, CAAs/root cause analysis and the plan of care

  • Discuss the benefits and potential challenges of providing person-directed cares.




Rai updates
RAI Updates

  • FY 2014 changes- effective 10/1/13

    • Distinct calendar days for therapy ( may effect Med A eligibility)

    • Discussion of “presumptive coverage”

  • RAI Manual updates

    • Modification/Inactivation policies

  • Challenges and concerns- Review

    • Need to open assessments timely

      • Regulatory guidelines

      • Financial concerns

      • Who is responsible for this task?

Rai updates1
RAI Updates

Impact and Tips

  • Increased awareness of “presumptive coverage” qualifiers

    • Medicare A coverage decisions

  • Scheduling /workload

  • Financial

Miscellaneous concerns
Miscellaneous Concerns

  • Quality Measures

    • How are they determined?

    • What do they mean?

  • Discharge Planning

    • New CMS focus and guidelines




Root cause analysis
Root Cause Analysis

  • Defining root cause analysis

    • “WHY? WHY? WHY?”

      • “SO WHAT??


    • Examples

  • Root cause analysis and the QA Process

    • Determine the reason for the concern

    • Develop a plan to manage the concern

    • Example: QM triggers for “Behaviors affecting others”

      • Which resident/s are triggering?

      • Which behaviors?

      • Why are the residents having these behaviors?

      • What can we do to manage the behaviors?

  • Using root cause analysis in documentation

  • Writing CAAs/Care plans

Documentation standards
Documentation Standards

Standards of Practice related to documentation

  • Proves that facility was providing care it was paid to provide (think Med A charting)

  • Required part of the resident’s care and validates that care was given

  • Proves that standards of care were met

  • Essential element of communication

Documentation standards1
Documentation Standards

Standards of Practice related to documentation

  • Reflective of resident response to cares and actions taken to rectify unsatisfactory response

  • Timely and completed only during or after giving cares

  • Chronological

  • Internally consistent

Documentation standards2
Documentation Standards

Charting consistency and objectivity

  • Documentation should reveal consistent interventions among disciplines

  • Consistency within the resident record

  • Quality of content, not quantity of words

  • Allegations about cares or comments about staff members should not be in charting

  • Avoid charting about staffing shortages (tx not done due to lack of staff)

Documentation standards3
Documentation Standards

Tips for improving documentation

  • Ensure consistency across all disciplines, as well as billing department

    • Strong documentation requires communication between disciplines to ensure that all are “on the same page”

    • Encourage each discipline to document only on their relevant areas

Documentation standards4
Documentation Standards

Documentation tips: what to document

  • Assessments, observations, concerns, interventions-cares and treatments

    • Incorporating critical thinking and root case analysis of what happened and why

  • Note action taken, resident response and evaluation

    • Critical thinking/root cause analysis—did it work? If not, what next?

Documentation standards5
Documentation Standards

Documentation tips: How to document

  • Be specific when describing behavior( not: “unruly” or “agitated” or “uncooperative”)

    • This does not really paint an accurate picture of what is happening with the resident

  • Document precipitating factors, what makes it better and what makes it worse

    • Incorporating root cause analysis

  • Document any specific resident statements

  • Document cares and interventions

  • Document resident response to cares and interventions

Documentation standards6
Documentation Standards

Documentation tips: Cares/treatment/intervention

  • Charting regarding cares/interventions and responses should be consistent with resident status

  • Describe resident response to any teaching, including understanding. List specific information given

  • Document all safety precautions taken to protect resident

Documentation standards7
Documentation Standards

Care Plan Documentation

  • Care plan should be updated when there is a change in resident status or resident orders

    • New interventions when there are new mood/behavioral concerns

    • If new med, is there an intervention needed to monitor effectiveness or side effects?

  • If interventions have been ineffective in past, probably should not be repeated (especially in case of falls/behaviors )

    • Incorporate root cause analysis to help determine why the interventions used previously were not effective and plan for other interventions that may be more appropriate

  • Care plan should match MDS and the resident’s current status

    • Ex: If MDS reflects short term memory deficit, reminder to use call light or call for assistance with tasks or activities may not be appropriate



Care Planning


  • CAA process guides the ID team through a comprehensive assessment of the resident’s functional status

  • Each CAA must be addressed, but may not need to be care planned

  • CAA documentation should address the reason that the CAA triggered

  • Identify:

    • Areas that warrant intervention

    • Areas that impact resident function

    • How to minimize decline and avoid functional complications

    • Address palliative care, including symptom relief and pain management



  • “Chart your thinking”

    • Documentation should include:

    • Nature of the condition

    • Underlying causes-diagnoses, conditions, meds, labs

    • Contributing factors-complications

    • Unique risk factors-complications, justification for care planning or not care planning

    • Need for referrals

    • Decision to proceed with care planning



  • Cognitive CAA

  • Communication CAA

  • Mood CAA

  • Behavior CAA

  • Psychosocial CAA


Areas of concern for each CAA:

  • Current status or level of function

  • Reason for the CAA to be triggering

  • Recent changes- improvements or declines

  • Precipitating factors /What makes the situation better or worse

  • Comparison to most recent prior MDS-BIMS and Mood scores, etc

  • Diagnoses and conditions

  • Meds, labs, treatments

  • Need for referrals

  • Other areas

  • Care Plan-develop, continue, revise

Caas and care planning
CAAs and Care Planning

Care Planning

  • Address areas as triggered in the CAA ( unless you decided not to proceed with care plan)

  • Combine care plan areas when it makes sense

  • Goals for improvement, prevention of complication or decline, palliative goals, maintenance goals

  • Care plan can address resident strengths and preferences

  • Involve resident and family or legal representative

Caas and care planning1
CAAs and Care Planning

Develop a plan of care which promotes:

  • Highest level of function,

  • Improvement when possible,

  • Maintenance and prevention of declines

Caas and care planning2
CAAs and Care Planning

Care Planning

  • Use the information you learned in the CAAs and root cause analysis to develop a plan of care that is specific and effective for that resident

  • Incorporate the resident’s goals and preferences as much as possible


    • Care plans can contain individualized approaches

  • Care plans are a working document and should be accessible to all staff

Care planning
Care Planning

  • Examples

    • What kind of help does the resident need and/or want?

    • When would s/he like the help?

    • What would s/he prefer to do for themselves?

    • What has worked or not worked in the past and why?

      • How will this affect care planning now?

Care planning1
Care Planning

Culture Change, Care planning and Person-directed Care:

  • Linda Bump is one the pioneers of the culture change movement

  • “Bump’s Law” can be the basis and driving force behind every decision- big or small.

    • What does the resident want?

    • How did the resident do it at his/her previous home?

    • How do you do it at home?

    • How should we do it here?

Envision person directed cares
Envision….Person-directed cares

  • Dining

  • Medications

  • Cares

  • Activities

  • Decorations and Furnishings

  • Policies

  • Staffing

  • Expanded Social History

  • Communication with families regarding the philosophy of culture change

Envision person directed cares1
Envision….Person-directed cares

  • Residents choosing and planning activities

  • Natural waking times

  • Easier medication administration

  • Staff self scheduling

  • Staff eating with residents

  • Residents decorating their living and common spaces

  • Meaningful engagement every day

Envision person directed cares2
Envision….Person-directed cares

“Person-directed care means we get out of the way when they express their preferences”

  • Put the resident at the center

  • Include the family

  • Educate

  • Know Best Practices

  • Write and implement clear policies regarding choice

Person directed cares
Person-Directed Cares

  • Tips for incorporating Person-Directed Care into the resident’s plan of care and daily life

  • Suggestions and sharing from the participants

Thank you
Thank You

Amy Ruedinger, RN, RAC-CT

Pinnacle Innovative Healthcare Solutions, LLC

(920) 609-7997



~Facilitating Peak Performance in

Senior Health and Housing ~