Welcome to this video series for skilled nursing facilities.
We will be discussing the MDS which is the Minimum Data Set
that is required for submission to CMS on a regular basis for every resident.
If you need more information than this short video can provide
please go to the www.cms.gov website for the most recent RAI Manual.
Today we'll be talking about signing off an MDS assessment.
As far as MDS goes there are two ways to think about "signing off".
One way is with your electronic health record (EHR) system software
which often includes a date and time stamp
and draws from your password to authorize your signature.
But not everyone has this sort of software.
The MDS way to think about signing off starts with section Z.
It is important to realize that these are two different things-
signing off in your software and signing off on MDS.
It is also important to know your company's policy about who signs off for each MDS section.
This is not dictated by MDS or by the state but by your company's policy and procedure manuals.
Ultimately the Director of Nursing is responsible to authorize each signer.
Each authorized signer is attesting to the accuracy of their work.
That means it is their responsibility to
be aware of all the RAI Manual intents, guidances and section options
for the items that they personally finished.
It can be that more than one person finishes a section.
In that case both people sign section Z, noting the specific items that they answered.
Each section must have at least one signer by the ARD date listed on A2300.
Then the RN Assessment Coordinator reviews the results in the grid in Section Z - again by the ARD.
The RN Assessment Coordinator can be
the Director of Nursing, a quality person or anyone else designated by the Director of Nursing
according to company policy.
According to MDS regs that person must be an RN with a currently valid license.
If there is an incomplete section the RN Assessment Coordinator is responsible
to get that Section signed under company policy by the ARD date.
That can mean an alternate Assessor is delegated
and must complete the assessment urgently.
Or it can mean that the RN Assessor must themselves
take responsibility to complete the Section.
When the RN Assessment Coordinator signs off on Z0500A and Z0500B
that means the entire assessment is done according to company policy.
Again remember that the accuracy of the section is the responsibility of the signer
not the RN Assessment Coordinator.
Once the section is signed off no revisions to individual items should be made
before submission to the central ASAP database even by a quality checker.
On comprehensive assessments attention should now be made
to the Care Area Triggers (CAT) and the Care Area Assessment (CAA) sign-offs in Section V.
For Section V the rules are similar in that authorized signers are responsible
for their individual care areas.
And one RN is responsible to see that the entire set is done according to company policy.
The RN signers for Section V and for Section Z do not have to be the same individual.
Once the assessment is submitted to the central ASAP database it may be discovered that there are errors.
Corrections are beyond the scope of this discussion
but are discussed in the RAI Manual under Chapter 3 - Section X.
Thank you for watching this video on MDS.
As always if you need further information please go to www.cms.gov for the most recent RAI Manual.
That's your best information.
Another good source of information is your state coordinator.
There is a list of your MDS coordinators in Appendix B of the RAI Manual.
Thank you for your time.