Ask Proactive – I recently started working as the MDS coordinator at a facility. MDS assessments have been scheduled, but no one completed them. What should I do to get back in compliance?

Q:

I recently started working as the MDS coordinator at a facility. MDS assessments have been scheduled, but no one completed them. What should I do to get back in compliance?

1. Assess the Extent of the Delay

• • Identify how many assessments are overdue and how far behind they are. Prioritize assessments based on the resident’s condition, CMS deadlines, and upcoming billing cycles. Note the following:
    • Significant change assessments are needed for appropriate plans of care
    • Medicare billing cannot be completed until assessments are completed and submitted
    • Discharge assessments impact PBJ
    • Missing MDS ARDs are not to be back dated. The ARD can be no earlier than the date the assessment was identified as missing.

2. Notify Relevant Team Members

• • Inform your nursing leadership, and administrators.
  • Communicate clearly to get necessary support and resources.

3. Create a Recovery Plan

• • Develop a catch-up schedule. If able work on current assessments to prevent any further late assessments while working on the overdue assessments.
  • Delegate tasks to the care team—RNs for interviews/assessments and IDT for assigned MDS sections.

4. Ensure Documentation is Complete and Accurate

• • Verify that nurses’ notes, therapy records, and physician documentation are up to date to support accurate MDS entries.

5. Maximize Your Software Tools

• • Use MDS software alerts, templates, and batch functions to improve efficiency.

6. Prevent Future Backlogs

• • Review and revise your internal MDS schedule.
  • Provide training if delays were due to knowledge gaps.
  • Assign backup staff to step in when primary MDS staff are unavailable.

Need help getting back on track?

Proactive’s expert MDS team provides Interim MDS Staffing, System Audits, and RAI Training & Education. Contact us today to learn more!

Written By:

Brandy Hayes, RN, RAC-CT, RAC-CTA

Clinical Consultant

Proactive LTC Consulting