I first want to start by advising Leadership to understand that this may be one of your most important roles to have filled in your facility.

The Registered Nurse in this role is responsible to ensure that the resident’s care needs have been thouroughly assessed by the interdisciplinary team.

The Final signature is regulated to be completed by a Registered Nurse.

Let’s examine that for a moment…..

Now the very fact that Nursing is made up by many nurses who vary in the profession based on what degree or license they hold has created tension within our profession. But if we are honest with ourselves those variations are why we have this regulation. Our education and license is what determines what our scope of practice is. Again, many will say that experience is what matters and not the letters after your name. Experience does count but again it is the fact that you are a RN that you are able to complete the final signing off of the most important part of the MDS that ensures the resident is getting the best care they deserve. Below I have included an excerpt from the MA Board of Nursing site to demonstrate why it is important to have a RN coordinate the MDS.

per: https://www.mass.gov/doc/244-cmr-3-registered-nurse-and-licensed-practical-nurse/download

3.02:  Responsibilities and Function – Registered Nurse

(1) A registered nurse shall bear full and ultimate responsibility for the quality of nursing care he or she provides to individuals and groups. Included in such responsibility is health maintenance, teaching, counseling, collaborative planning and restoration of optimal functioning and comfort or for the dignified death of those they serve. A registered nurse, within the parameters of his or her generic and continuing education and experience, may delegate nursing activities to unlicensed persons in accordance with 244 CMR 3.05:

(2) A registered nurse shall act, within his or her generic and continuing education and experience to:

(a) systematically assess health status of individuals and groups and record the related health data;
(b) analyze and interpret said recorded data; and make informed judgments there from as to the specific problems and elements of nursing care mandated by a particular situation; (c) plan and implement nursing intervention which includes all appropriate elements of nursing care, prescribed medical or other therapeutic regimens mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field; (d) provide and coordinate health teaching required by individuals, families and groups so as to maintain the optimal possible level of health;

(e) evaluate outcomes of nursing intervention, and initiate change when appropriate;
(f)collaborate, communicate and cooperate as appropriate with other healthcareproviders to ensure quality and continuity of care; and
(g) serve as patient advocate, within the limits of the law.

3.03:  Designation – Practical NurseLicensed practical nurse

is the designation given to an individual who is a graduate of a Board approved practical nursing program, and who is currently licensed as a practical nurse pursuant to M.G.L. c. 112. The licensed practical nurse functions within the framework specified by the nursing statutes and regulations of the Commonwealth.

3.04:  Responsibilities and Functions – Practical Nurse

(1) A licensed practical nurse bears full responsibility for the quality of health care she or he provides to patients or health care consumers. A licensed practical nurse within the parameters of his or her generic and continuing education and experience, may delegate nursing activities to unlicensed persons in accordance with 244 CMR 3.05

(2) A licensed practical nurse participates in direct and indirect nursing care, health maintenance, teaching, counseling, collaborative planning and rehabilitation, to the extent of his or her generic and continuing education and experience in order to:

(a) assess an individual’s basic health status, records and related health data;
(b) participate in analyzing and interpreting said recorded data, and making informed judgments as to the specific elements of nursing care mandated by a particular situation; (c) participate in planning and implementing nursing intervention, including appropriate health care components in nursing care plans that take account of the most recent advancements and current knowledge in the field;
(d) incorporate the prescribed medical regimen into the nursing plan of care;
(e) participate in the health teaching required by the individual and family so as to maintain an optimal level of health care;
(f) when appropriate, evaluate outcomes of basic nursing intervention and initiate or encourage change in plans of care; and
(g) collaborate, cooperate and communicate with other health care providers to ensure quality and continuity of care.

Again, please note that experience does play an important role when determining if a nurse is able to complete a job requirement. It is also just as important to determine if they have the license that ensures they can complete the role within their scope of practice that they are being considered for.

So in terms of the MDS assessment what does that mean?

Well you may say that the MDS RN signature only ensures it is complete:

Below is the literature directly from the RAI manual re: signatures for the completion of any section of the MDS:

http://mds-3.0-rai-manual-v1.17.1_october_2019-2.pdf pages 597-598

Item Rationale

• To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement.

Z0400: Signatures of Persons Completing the Assessment (cont.) • The importance of accurately completing and submitting the MDS cannot be over-

emphasized. The MDS is the basis for:

— the development of an individualized care plan;
— the Medicare Prospective Payment System
— Medicaid reimbursement programs
— quality monitoring activities, such as the quality measure reports — the data-driven survey and certification process

— the quality measures used for public reporting — research and policy development.

Coding Instructions

• All staff who completed any part of the MDS must enter their signatures, titles, sections or portion(s) of section(s) they completed, and the date completed.
• If a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed.
• Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS, to the best of your knowledge, most accurately reflects the resident’s status. Penalties may be applied for submitting false information.
• Coding Tips and Special Populations

• Two or more staff members can complete items within the same section of the MDS. When filling in the information for Z0400, any staff member who has completed a sub- set of items within a section should identify which item(s) he/she completed within that section.
• Nursing homes may use electronic signatures for medical record documentation, including the MDS, when permitted to do so by state and local law and when authorized by the nursing home’s policy. Nursing homes must have written policies in place that meet any and all state and federal privacy and security requirements to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs.
• Although the use of electronic signatures for the MDS does not require that the entire record be maintained electronically, most facilities have the option to maintain a resident’s record by computer rather than hard copy.
• Whenever copies of the MDS are printed and dates are automatically encoded, be sure to note that it is a “copy” document and not the original.

October 2019 Page Z-5

CMS’s RAI Version 3.0 Manual CH 3: MDS Items [Z]

Z0400: Signatures of Persons Completing the Assessment (cont.)

• If an individual who completed a portion of the MDS is not available to sign it (e.g., in situations in which a staff member is no longer employed by the facility and left MDS sections completed but not signed for), there are portions of the MDS that may be verified with the medical record and/or resident/staff/family interview as appropriate. For these sections, the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted. For sections requiring resident interviews, the person signing the attestation for completion of that section should interview the resident to ensure the accuracy of information and sign on the date this verification occurred.

Z0500: Signature of RN Assessment Coordinator Verifying Assessment Completion

Item Rationale

• Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete.

Steps for Assessment

1. Verify that all items on this assessment are complete.
2. Verify that Item Z0400 (Signature of Persons Completing the Assessment) contains attestation for all MDS sections.

Coding Instructions

• For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator. This date must be equal to the latest date at Z0400 or later than the date(s) at Z0400, which documents when portions of the assessment information were completed by assessment team members.
• If for some reason the MDS cannot be signed by the RN assessment coordinator on the date it is completed, the RN assessment coordinator should use the actual date that it is signed.
• Coding Tips

• The RN assessment coordinator is not certifying the accuracy of portions of the assessment that were completed by other health professionals.

What does that all mean for your residents?

The RN may not be certifying the accuracy of the portions by others but the RN does ensure that each section that was completed has an attestation signed. If it does not then that nurse will have to validate who did it, have them sign it, or validate was this autopopulated and no one reviewed it. If that is the case it is this Nurse who most likely will complete and sign the attestation for sections that have not been completed in order to complete the MDS assessment per designated time requirement.

Lets take a deeper look at what the RN who signs off the MDS as complete may do. I am writing from experience of that RN who has signed the MDS as complete.

In this role, I have managed both the scheduling of the MDS for both OBRA and Reimbursement requirements that the MDS is utilized for.

This ensured the following 2 scenarios were accomplished

1. The resident received a comprehensive assessment within 14 days of admission and a comprehensive person centered care plan was completed within the regulatory requirement.
2. The facility was accurately able to capture the correct financial reimbursement category for the care provided.

As Nurses, we do not like to think of the financial part of the MDS but it is important to keep in mind that this is the tool that regulates revenue to provide the best care possible for our elderly. Ensuring elders receive the care they truly deserve is close to my heart. Sometimes, the financial implications of inaccurate MDS assessments can impact the level of care they receive.

In most companies today, there is a last QM check system that is initiated when a MDS is being locked as complete by the R.N. completing this step.

This is another very important step as it flags anything that was coded that may not make sense. It also flags any area that may be quality measure concern.

This is the point where as a R.N you will use your scope of practice and “analyze and interpret said recorded data; and make informed judgments there from as to the specific problems and elements of nursing care mandated by a particular situation; (c) plan and implement nursing intervention which includes all appropriate elements of nursing care, prescribed medical or other therapeutic regimens mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field; (d) provide and coordinate health teaching required by individuals, families and groups so as to maintain the optimal possible level of health;” – RN nurse practice Act

Remember ………

If you code accurately ………

Then your residents will be provided the best care…………………….

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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