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Test Your Knowledge Answers:

1) The influenza vaccine has not been given for this year’s flu season. You must determine the reason it was not given to appropriately code section O.

Pages O-8 and O-9 of the RAI User’s Manual state:

• Code 1, Resident not in this facility during this year’s influenza vaccination season: resident was not in this facility during this year’s influenza vaccination season.

• Code 2, Received outside of this facility: includes influenza vaccinations administered in any other setting (e.g., physician's office, health fair, grocery store, hospital, fire station) during this year’s influenza vaccination season.

• Code 3, Not eligible—medical contraindication: if influenza vaccine not received due to medical contraindications. The influenza vaccine is contraindicated for a resident with severe reaction (e.g., respiratory distress) to a previous dose of influenza vaccine or to a vaccine component. Precautions for influenza vaccine include moderate to severe acute illness with or without fever (influenza vaccine can be administered after the acute illness) and a history of Guillain-Barré Syndrome within six weeks after the previous influenza vaccination.

• Code 4, Offered and declined: resident or responsible party/legal guardian has been informed of the risks and benefits of receiving the influenza vaccine and chooses not to accept vaccination.

• Code 5, Not offered: resident or responsible party/legal guardian not offered the influenza vaccine.

• Code 6, Inability to obtain influenza vaccine due to a declared shortage: the vaccine is unavailable at this facility due to a declared influenza vaccine shortage.

• Code 9, None of the above: if none of the listed reasons describe why the influenza vaccine was not administered. This code is also used if the answer is unknown.

2) See the RAI Manual, chapter 2 under “Reentry.” The resident would be considered a reentry if they return within 30 days FROM the date of discharge. So, the count would start on the day after the discharge. If the resident discharged from the building on September 20 (return anticipated), she would be a re-entry up until and including October 20. A1600 would change to the reentry date but A1900 would remain as the original admission date.

If the resident came back to the facility on October 21 or later, she would require a new admission (where A1600 and A1900 are both reset to the new date of admission, and a new admission comprehensive assessment would be required).

Of course, if the discharge had been coded as “return not anticipated”, then a new admission process is required even if the resident came back to the facility within 1 day.

3) Transfers are only one part of the Toilet Use ADL. It sounds like staff members complete the hygiene sub-task of toilet use completely. The correct code would be extensive assistance.

See RAI page G5

• Code 3, extensive assistance: if resident performed part of the activity over the

last 7 days and help of the following type(s) was provided three or more times:

- Weight-bearing support provided three or more times, OR

- Full staff performance of activity three or more times during part but not all of the last 7 days

providing the task of peri care/toilet hygiene by staff would be full staff performance for that part or sub-task of toileting.

4) If the resident has one of the following three diagnoses: Schizophrenia, Tourettes, or Huntington's, check Section I to confirm the boxes for the above diagnoses have been checked. Adding the diagnoses to I8000, will not exclude them from the numerator on your QM reports.

5) CMS previously clarified a similar question: If the resident is on LOA, and is subsequently admitted to the hospital while on LOA, the day of discharge is the date the resident initially left the facility.

6) In this scenario, the weight loss on the May 2022 SCSA was not coded. The correct steps would be to modify the May 2022 SCSA to correct the weight loss item and transmit the corrected assessment. This was also a significant error. A Significant Correction of a Prior Comprehensive assessment must be completed within 14 days of determining the significant error that occurred. The ARD cannot be before the determination of significant error.

7) This would not be a discharge.

See the definition of discharge on page 2-10 of the RAI User’s Manual:

Discharge refers to the date a resident leaves the facility or the date the resident’s Medicare Part A stay ends but the resident remains in the facility. A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is considered the actual date of discharge. There are three types of discharges: two are OBRA required—return anticipated and return not anticipated; the third is Medicare required—Part A PPS Discharge. A Discharge assessment is required with all three types of discharges. Section 2.6 provides detailed instructions regarding return anticipated and return not anticipated types, and Section 2.8 provides detailed instructions regarding the Part A PPS Discharge type. Any of the following situations warrant a Discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds:

• Resident is discharged from the facility to a private residence (as opposed to going on an LOA);

• Resident is admitted to a hospital or other care setting (regardless of whether the nursing home discharges or formally closes the record);

• Resident has a hospital observation stay greater than 24 hours, regardless of whether the hospital admits the resident.

It’s a leave of absence, so it counts the day they were out at midnight as a non-billable skip day, and make sure you don’t use it as the ARD of an MDS.

See the definition of leave of absence on pages 2-13 of the RAI User’s Manual:

Leave of Absence (LOA), which does not require completion of either a Discharge assessment or an Entry tracking record, occurs when a resident has a:

• Temporary home visit of at least one night; or

• Therapeutic leave of at least one night; or

• Hospital observation stay less than 24 hours and the hospital does not admit the resident.

Providers should refer to Chapter 6 and their State LOA policy for further information, if applicable.

There is also a two-paragraph passage in chapter 8 of the Medicare Benefits Policy Manual that addresses LOAs (pages 43-44). This is very much worth looking at not only because it’s good to know the rules but also because I think it’s a nice example of how humane and practical CMS can be.

8) Yes, this is considered an intercepted fall, which is still considered a fall.

From the RAI User’s Manual, page J-28:

“An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person – this is still considered a fall.”

P.S. - Keep a lookout in the upcoming Broadcasts for information on the MDS changes coming October 2023!