This week’s “Ftag of the Week” on the CMSCG Blog is part of the Resident Assessments regulatory group, F637 Comprehensive Assessment After Significant Change. The intent of this regulation is to ensure that a resident who experiences a significant change in status has a comprehensive assessment completed within 14 days of the facility determining that there has been a significant change.
What’s a significant change? Let’s start with some key definitions from Appendix PP of the State Operations Manual (SOM).
“Significant Change” – Either a major decline or improvement in a resident’s status that:
- Will not normally resolve itself without staff intervention or implementation of standard disease-related clinical interventions
- Impacts more than one area of the resident’s health status
- Requires an interdisciplinary review and/or revision of the resident’s plan of care
- Is a decline non considered self-limiting
“Self-limiting” – Refers to a condition that will typically resolve without further intervention, including implementation of clinical interventions, to resolve.
“Significant Change in Status Assessment” – A SCSA is the comprehensive assessment that needs to be completed when the IDT has determined that the resident meets the guidelines related to improvement or decline in condition. If the resident’s condition is not expected to return to his/her baseline within two weeks, the SCSA must be completed. This assessment must be completed within 14 days of the determination that the resident’s status has changed significantly compared to the resident’s most recent comprehensive assessment and most recent quarterly assessment.
Significant Change in Status Assessments
There are many changes that can be considered a decline in a resident’s condition, including a change in the resident’s decision-making ability, frequency/severity of behavioral symptoms of a resident living with dementia (which indicate a change in the disease process since the prior assessment), or changes related to ADL functioning, incontinence or emergence of certain types of pressure ulcer. The IG provides a list of areas that are considered declines, and this is worth reviewing to ensure the team is aware of everything that would trigger a SCSA after a resident exhibits a decline.
Let’s look at how this can be cited on survey:
Recertification Survey – F637 S/S: D
A facility was cited for failure to ensure that a Significant Change MDS was completed and transmitted within the appropriate time frame for 1 resident. The resident was coded as requiring limited assist for several ADLs (bed mobility, bathing and walking in his/her room), experienced a significant decline and then required extensive assist to perform the same ADLs. The resident had stopped walking and required extensive assistance for bed mobility, and also had an unplanned significant weight loss. The facility should have completed a SCSA due to the decline in 2 ADLs and the significant weight loss.
Likewise, a resident’s noted improvement can trigger a SCSA. This would be appropriate when there is a decrease in the number of areas where behavioral symptoms are being coded as present or when the resident has an improvement in ADL function where the resident is newly coded as Independent/ Supervision/ Limited assistance since the last assessment and does not reflect a normal fluctuation in that resident’s functioning.
According to the Interpretive Guidance at F637, A SCSA is appropriate when:
- There are two or more MDS areas with decline
- There are two or more MDS areas with improvement
- The IDT determines that the resident would benefit from an assessment and revisions to the resident’s plan of care.
The IG notes that in some circumstances, even if only one change has been identified, that the IDT may determine that the resident could benefit from a SCSA. If a SCSA is completed, but does not meet the criteria for completion, the rationale must be documented in the medical record.
There are also requirements for when the SCSA MDS must be completed – and this is where many providers end up cited on survey, so pay attention. These include:
- When a resident enrolls in hospice
- When a resident changes hospice providers but remains in the facility
- When, as noted above, the resident experiences a consistent pattern of changes where two or more areas of decline or improvement from the resident’s baseline have been identified.
Let’s look at another survey citation related to when two opportunities for a Significant Change Assessment were missed by the provider and were identified by a surveyor onsite during a survey.
Recertification Survey – F637 S/S: E
While conducting observations during survey, a surveyor identified a resident who staff determined was cognitively impaired and a wanderer. The surveyor reviewed the resident’s record and determined that the resident was noted with significant improvement in functional status and worsening behaviors on the two most recent quarterly assessments – which should have triggered a SCSA.
The surveyor observed another resident in bed and during an interview, the resident stated that he needed help from staff for care. A review of the resident’s MDS Assessments found that the resident had experienced an improvement in functional status for bed mobility, transfer, toilet use and eating. The resident had also experienced a decline in his mood which impacted his appetite and he had experienced a decline in behaviors, as reflected in the MDS that he was exhibiting less verbal behavior symptoms towards others. There was no documented evidence that a SCSA had been initiated when the resident experienced significant improvement in functional status and decline in mood and behavior.
The surveyor then used the relevant sections of the MDS Manual as references to show exactly what the facility missed and why. Per the facility, it did not have a Significant Change policy, and they followed the requirements in the MDS Manual. This surveyor clearly pointed out what they had missed.
There are a couple of points to note about ensuring the timeliness of a SCSA:
- A SCSA cannot be completed until after a Comprehensive Admission assessment has been completed
- MDS sections Z0500B and V0200B2 are signed as complete by the 14th calendar day after the determination date that a significant change has occurred
Facilities can be cited related to timeliness of submission as well. Here’s another survey citation to review:
Recertification Survey – F637 S/S: D
A facility was cited for failure to complete and submit a Significant Change assessment for a resident who had experienced an ADL decline, but a SCSA was not completed. The resident’s ADL Care Plan evaluation documented that there was no significant change from the prior assessment despite the resident now requiring total assistance for several ADLs. Staff responsible for caring for the resident were interviewed regarding the resident’s change in care needs. The Administrator and DON were unable to explain why the MDS was not accurate or submitted in a timely manner.
Don’t forget, the surveyors have access to the RAI Manual during survey, so they are easily able to catch errors. Citations for the F-tags related to MDS Assessments have been on the rise over the past few years, so ensure staff are appropriately following the requirements for assessments.