Does anyone out there care?

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?

Some facilities have truly embraced the “prospective payment” format; they are actually conversant on how it was designed to work and have avoided completing extra quarterlies via the established “loophole” in the system. Others simply play along with whatever “holes” are provided, including the capability of completing a new quarterly when something changes that can improve that particular resident’s case-mix at that point. There are no criteria to be met, no restrictions of “how many quarterlies can be completed early,” and no directives whatsoever to document “why” that additional assessment was completed. CMS is supposed to be worried about the budget. I have been told that the states’ hands are essentially tied as long as there are no changes in the MDS 3.0 guidelines-and this loophole remains open.

Facilities that have held the ethical line are now finding themselves competing with those who took advantage-strictly for monetary purposes-because no significant change assessments were implemented that mandated a more in-depth assessment for the resident’s benefit.

It was hoped that the changes that are being talked about for the MDS 3.0 would include a removal of the “minimum” of three quarterly components. How hard would it be to define the fact that it might be to the facility’s benefit to move assessments up earlier, and result in the entire cycle of three quarterlies then an annual be completed early-with documentation placed in the medical record to validate why it was necessary?

My personal assessment of the MDS 3.0 is that it was systematically retooled to withdraw many of the loopholes that were present in the MDS 2.0 that permitted facilities to capture and get paid for services that were not being provided at the time, through Medicare. Admirable, I guess. But it also leaves a blatant hole in place that skews the prospective payment basis for the states via the OBRA assessments.

For facilities where I have consulted in the past and those who will be attending scheduled upcoming MDS 3.0 trainings, I find it very difficult to teach a process that simply “does not make any sense.” But, I am now forced to bring it to their attention that to compete against those who have always looked for and used loopholes to gain a buck, they should simply swallow real hard-and follow suit. What does that say about our industry when those who have truly struggled to provide good care and do things ethically and according to the guidelines suffer when placed against individuals who do not? And, those concerns go way beyond the quarterly issue, which could have been such an easy fix.

I thought the new MDS 3.0 tool was to reflect the resident’s needs and that is why it was implemented to begin with. Most hands-on nurses in the facilities in any state I have visited, have no comprehension regarding the majority of the MDS process, which is a travesty. There are no incentives to “teach” them true individualized resident assessment-unless they are focusing on the reimbursement component. And those skewed statistics are compared with the facilities that involve staff and work hard to maintain compliance with the guidelines, resulting in unfair determinations throughout, whether it is reimbursement, QI/QMs or that highly questionable Five-Star Quality Rating System.

Janet Gerber RN-BC, is President/CEO of Pennsylvania-based Gerber Consulting Services, Inc. For more information, call (724) 254-2987 or visit

www.gerberconsulting.com. Long-Term Living 2011 August;60(8):8-9

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