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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 ~