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Does anyone out there care?

August 17, 2011
by Janet Gerber, RN-BC
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Janet Gerber, RN-BC
Janet Gerber, RN-BC


Mathematically, I have always “assumed” that if you were dividing a whole into “quarters” that would mean you would have four equal parts. Among the definitions of quarter, in a measurement context are (according to

www.dictionary.reference.com/browse/quarter: (1) one of the four equal or equivalent parts into which anything is or may be divided: a quarter of an apple; (2) one fourth of a U.S. or Canadian dollar, equivalent to 25 cents; (3) one fourth of an hour; and (4) one fourth of a calendar or fiscal year.

Purportedly, the instrument now used to assess residents in long-term care facilities throughout the United States was compiled by some of most highly educated individuals and research teams in this great nation. How, then, can these groups defend the fact whereby more than four quarters can comprise a whole?

I have been asking this question since I first read through the proposed MDS 3.0 manual, before its implementation. And supposedly highly educated personnel within our governmental agencies, when asked about this problem, simply respond that the current edition of the RAI User's Manual (September 2010) states the following with regard to quarterly assessments:

  • Federal requirements dictate that, at a minimum, three Quarterly assessments be completed in each 12-month period. (page 2-30)

  • OBRA assessments may be scheduled early if a nursing home wants to stagger due dates for assessments. As a result, more than 4 OBRA Quarterly assessments may be completed on a particular resident in a given year. (page 2-31)

Remember, our government is telling us to be fiscally prudent-and yet they do not comprehend that when dividing a whole into quarters, you really shouldn't come up with five or six.

From the responses that I have received to my inquiries, the use of the verbiage “at a minimum,” sets the process up to ensure just that-a minimum. Also be very much aware that if a Significant Change Assessment is implemented at any time following a Comprehensive Admission Assessment, the annual “clock” component begins all over again without any designation of having completed a minimum three quarterlies. What then would have been so difficult about removing the term “minimum” of three quarterlies in each 12-month period?

If representatives from the Centers for Medicare & Medicaid Services (CMS) wanted to permit anyone to complete an additional assessment whenever they wanted to drive reimbursement upward, why not just say so? After all, that is essentially what has occurred. Remember, our government is telling us to be fiscally prudent-and yet they do not comprehend that when dividing a whole into quarters, you really shouldn't come up with five or six.

Consultants that are directly attached with some well-known accounting firms have advised facilities to complete more than four quarterly assessments, whenever they feel the result will drive up the Medical Assistance reimbursement-or MA-CMI. The basis for “prospective payment” is lost with that approach. And the ability to compare facilities within peer groups moving forward has become all but impossible because there has been no continuity to the approach. Those facilities that have ethically evaluated the process and not completed any extra quarterlies for simple payment only are the ones that are ultimately suffering. And I accept part of that blame because I try to teach those values to my clients.

Direct contact with representatives from CMS regarding this concern has resulted in no answers other than the one that is provided in this article. It was almost surreal when an MDS coordinator informed me that there was no comprehension that an OBRA assessment impacted reimbursement at all-and that was fewer than three months ago. She was involved with the Medicare side. When you talk to someone that has worked on the terminology used to complete various sections of the MDS, there is very often little, if any, acknowledgment of how those answers might impact either Medicare or state Medicaid reimbursement-or the potential impact on the survey process that is addressed within Appendix PP of the State Operations Manual. Those individuals have been extremely cordial but fully admit that the process is segmented. Yet, individuals who attempt to manage nursing facilities are held accountable for a full understanding of the entire process and the ability to comply accordingly.

Can anyone see how very broken this system remains? We have all heard about the “bumps in the road” and how change is not without its problems. I agree. But when something that is as basic as four parts in a whole is not understood, what confidence can we have when those who hold the purse strings don't seem to grasp the problem?

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