When completing the MDS, timing can make all the difference, especially when it comes to signatures. A late signature can invalidate an entire section of the MDS, or more, resulting in noncompliance and survey citations. Are you or members of your team making these common signature errors?
1) Signing for the interview too late at Z0400
When it comes to MDS interviews (Cognition, Mood, Preferences, and Pain), the requirement is that Z0400 be signed on or before the assessment reference date (ARD). If Z0400 is signed after the ARD, the interview is not considered completed.
One common mistake is that although an interview is completed timely, the documentation and signature are not. If an interview is not completed timely, you need to then dash the items. If the interviews are completed timely but not signed off on time they would be considered invalid, which could lead to noncompliance and survey citations.
Time management when scheduling interviews is imperative, preventing tardy and invalid submissions. Not only must interviews be scheduled at appropriate times, they must be scheduled with enough flexibility that, if the resident becomes unavailable, the assessor can reschedule interviews and remain within the mandated time frame.
To prevent errors, there must also be very good communication between the interdisciplinary team (IDT) and the NAC. The NAC needs to communicate interview deadlines as established by the ARD to other departments responsible for specific interviews to ensure that an interview is not missed.
2) Confusion over who can sign Z0500
It is imperative that an RN who understands the resident assessment instrument and requirements attest to completion of the MDS assessment (item Z0500A.) The signature in that item must be of an RN – not an LPN. Although this is not a problem in most facilities on a good day, there are times when the RN might be out of the facility and an LPN, acting as a backup, thinks, “I’m just going to get this done and sign off because I have a deadline.” Staff education about who can sign Z0500 is critically important. Educators should emphasize that under no circumstances should anyone other than an RN with an understanding of the Z0500 sign off on the MDS, communicating the negative implications if signed by an LPN, etc.
3) Signing off for CAAs at V0200B without reviewing first
Signing for the completion of CAA notes, V0200B, has the same deadline as the MDS completion. This item should be signed off by an RN, who in signing is verifying that the CAA notes have been completed by her and the IDT. In some cases, the RN does not have a full understanding of what he or she is signing for in validating the completion of CAA notes. Depending on the software used, as soon as any member of the IDT signs off on his section of the CAA notes, the item may appear as if completed. For example, the item may turn green or show a check mark. If the NAC sees this list of “completed” items and doesn’t open each to review and verify that it is in fact complete, there is a greater likelihood that some sections will be missing information. Therefore, the signature attesting that these items are complete could be inappropriate. The RN signature and date at V0200B certifies completion of the comprehensive assessment. Every RN signing off for CAA notes needs to know what he or she is certifying , be familiar with the software, and give each section the diligence it demands. The date at V0200B2 should then be used to determine the date by which the care plan must be completed (V0200B2 + 7 days).
4) Signing for the care plan at V0200C based only on whether the decision has been made to proceed
When signing for the care plan decisions at V0200C, the signature indicates that the care plan decision has been made on or by the date signed. This may lead the NACs to assume that just having the care plan decision made during completion of the CAA note is enough to justify signing off on the care plan. However, the care plan decision should be made only after the decision has been made by the interdisciplinary team AND the comprehensive care plan is complete. The signature does not have to be the NAC or RN, the person(s) who facilitates the care plan decision making is able to sign the completion date.
5) Misunderstanding the timing and order of signatures for Z0400 and V0200B
When an IDT member signs off at Z0400, he is attesting that every item is completed accurately in the sections for which he is responsible. Ideally the completion of the CAAs would occur after all items on the MDS have been signed for at Z0400. The Care Area Triggers (CATs) are very dynamic and it’s possible that the IDT members may not have all contributing factors, risks, or considerations from the triggers if the CAA notes are completed too early. This can lead to CAA notes that are incomplete or inaccurate. This may happen when, for example, an IDT member (such as a dietitian) works at multiple facilities and is only present to complete her sections on specific days. If early completion of the CAA is unavoidable, the NAC will need to review the CAA after the MDS has been completed and provide updates to ensure it is accurate and considers all causal factors. If the CAA note remains incomplete or inaccurate, it could result in an inaccurate or incomplete care plan.
It is important to remember that the care plan should be completed by the IDT—as a team working together—rather than in a multidisciplinary fashion whereby each team member writes his or her own section independently. When the latter happens, there tends to be a lot of overlap or missing information. Be sure that within your IDT, team members complete their respective tasks in collaboration with other team members to prevent unintended consequences.
Most signature errors are completely avoidable with some extra staff education and attention to detail. Even on a busy day, remember to keep clearly in mind what exactly it is you are signing for, and don’t let it get lost in the shuffle.
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