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
 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
&
OTHER CONCERNS
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 Updates
Impact and Tips
Increased awareness of “presumptive coverage”
qualifiers
Medicare A coverage decisions
Scheduling /workload
Financial
Miscellaneous Concerns
Quality Measures
How are they determined?
What do they mean?
Discharge Planning
New CMS focus and guidelines
ROOT CAUSE ANALYSIS
&
DOCUMENTATION
Root Cause Analysis
 Defining root cause analysis
“WHY? WHY? WHY?”
“SO WHAT??
WHY IS THIS IMPORTANT?”
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
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 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 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 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 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 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 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 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
CAAS
&
Care Planning
CAAs
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
CAAs
ROOT CAUSE ANALYSIS
 “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
CAAs
CAAs:
Cognitive CAA
Communication CAA
Mood CAA
Behavior CAA
Psychosocial CAA
CAAs
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
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 Planning
Develop a plan of care which promotes:
 Highest level of function,
 Improvement when possible,
 Maintenance and prevention of
declines
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
PERSON-DIRECTED CARE
Care plans can contain individualized approaches
Care plans are a working document and should be
accessible to all staff
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 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
Dining
Medications
Cares
Activities
Decorations and Furnishings
Policies
Staffing
Expanded Social History
Communication with families regarding the
philosophy of culture change
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 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
Tips for incorporating Person-Directed Care into the
resident’s plan of care and daily life
Suggestions and sharing from the participants
Thank You
Amy Ruedinger, RN, RAC-CT
Pinnacle Innovative Healthcare Solutions, LLC
(920) 609-7997
E-mail: pinnaclemds@yahoo.com
E-mail: amy@pinnacleinnovativesolutions.com
~Facilitating Peak Performance in
Senior Health and Housing ~