Section 2.6 Plan
Implementation Strategies for Assessments
Use this tool to help ensure that all assessment requirements prior to and during a resident's stay in
your facility can be documented in an efficient and effective manner.
Time needed: 24 – 40 hours
Suggested prior tools: 2.8 Workflow and Process Redesign for EHR and HIE
How to Use
1. Determine the nature of the assessments you are required to make by state law and to fulfill
accrediting requirements.
2. Determine that each assessment can be documented using your health information technology
(HIT) system.
3. During planning for HIT acquisition you should have mapped, in detail, current workflows and
processes associated with performing assessments. You should also have identified processes you
wanted to include in the new application and how improvements were to be made. Pull these out.
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If mapping was not previously done, conduct workflow and process improvement
mapping to determine how each assessment requirement will be implemented,
including making decisions about how current workflows and processes will change.
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Test the new workflows by applying the various scenarios different users created
during the selection process. Make sure that the workflows and process changes that
the new HIT imposes are workable in your environment. Ensure that all nursing staff
and others, if appropriate, are fully engaged in this process. Stress the importance of
following policies and procedures and reporting any issues or concerns regarding
use. Because HIT processes are often quite different from manual processes, staff
members who may be uncertain about how to handle exceptions often revert back to
old manual processes by default rather than seeking advice on how to handle the
exception in the system. Workarounds are created, continue, and can produce
misleading or erroneous outcomes—a result that is potentially detrimental to the
resident and/or the organization.
Documenting the Admission Process
A number of documents need to be completed to admit an individual to a skilled nursing facility.
Many requirements are state-specific and some relate to the nature of the potential resident’s health
status, his or her medical diagnoses, and which services the facility is licensed to provide. With
respect to HIT, these three ingredients are key to documentation that supports an admission.
1. Incorporating paper forms. Many forms that are completed prior to admission come from
external sources, such as hospitals, physician offices, etc., in paper format. In addition, many
skilled nursing facilities may continue to use some paper forms for residents or their
families/caregivers to complete. Paper forms often include the application for admission,
preadmission screening assessment, consent for treatment, consent to photograph, physician
certification for Medicare, interagency transfer forms, mental illness and mental retardation
form (state-specific), acknowledgement of receipt of the notice of privacy practices,
Section 2 Plan—Implementation Strategies for Assessments - 1
resident’s bill of rights, admission agreement, and advance directives. If the individual has
not yet been admitted and logged into the admission-discharge-transfer (ADT) component of
the system, a physician order for immediate care may be received on paper. In order to
achieve a paperless environment and create the ability to access this information as needed, a
document imaging system is often used to scan the paper documents into the HIT or
electronic health record (EHR) system. If the skilled nursing facility participates in a health
information exchange (HIE), receiving some of these documents as an electronic feed
directly from their source may be possible.
2. Workflow support. For staff processing of the admission forms and to manage requirements
for later renewal of these documents, an electronic document management systems (EDMS)
component with workflow functionality may be desirable. This enables the facility to log
referrals into a waiting list and monitor completion of the application, preadmission
screening, and physician certification. If the HIT includes a staffing component, staff
members can be assigned to admit the resident when he or she is expected, including
designating additional electronic documentation that must be completed.
3. Transition to automated documentation. In addition to scanning documents and managing
workflow during the admission process, enter as much as the information as feasible directly
into the system. This can be accomplished by the referring party using a portal and/or
transmitting the Continuity of Care Record (CCR) or Continuity of Care Document (CCD,
using the HL7 Clinical Document Architecture, CDA). By the time the resident is admitted,
registration staff members should have entered demographic information into the system and
a face sheet or electronic file should have been created for the patient. By the time the
resident assessment instrument (RAI) is due to be completed, staff should also have entered
the resident’s information into the electronic health record (EHR) or other HIT. The staff
then should be able to complete all remaining internal documentation using the system,
including taking advantage of prompts and reminders for when various documentation
elements are required for the resident, based on the resident assessment protocol (RAP) and
care plans.
Challenges to Capabilities
The functionality that your HIT or EHR affords determines your opportunity for improvement in
productivity and timely, complete, and accurate documentation. The following are some
considerations:
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If your skilled nursing facility is required to include a physician history and physical exam in
its RAI process, the source may be paper or a digital document (e.g., physician dictation that
may be electronically fed to your system). The extent to which the various assessment
components of the RAI are performed—via the EHR or other HIT or from external
sources—will determine the extent to which RAI data will flow directly into the minimum
data set (MDS) component in the system. Ideally, staff members should not have to re-enter
data into the MDS component, but documents that are scanned or electronically fed into your
system and are not structured data will not automatically populate the MDS.
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The ability to automate MDS data directly impacts how well the MDS data points can
automatically notify staff of a RAP trigger. This further impacts the timely completion of
other assessments, care plan development, and care plan implementation—all of which also
impact the facility’s evaluation on Medicare.gov Nursing Home Compare, etc.
Documentation of Assessments and Care Plan
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An RAI enables the skilled nursing facility’s care team to assess each resident according to a
standardized data set at specific times during the admission and alert staff that conditions triggered
by RAPs are present and need evaluation. RAP triggers should be incorporated into the EHR or other
HIT in order to identify potential problems that may require further assessment, offer screening
triggers that allow further identification of problems, identify residents at risk for specific problems,
and identify possible rehabilitation opportunities. The ideal system should not only facilitate
compliance with MDS or RAP assessments but integrate other assessments, as well, to support the
care planning processing. Once again, data collected for all assessments needs to be structured data,
not from narrative notes.
The ultimate goal of assessment data collection is to assure that an interdisciplinary care plan is
developed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial
well-being (see CMS 2012 State Operations Manual). The Centers for Medicare & Medicaid
Services (CMS) also defines a comprehensive care plan as one in which an “interdisciplinary team,
in conjunction with the resident, resident’s family, surrogate, or representative should develop
quantifiable objectives for the highest level of functioning the resident may be expected to attain,
based on the comprehensive assessment.” The American Health Care Association (at:
http://www.ahcancal.org/facility_operations/ComplianceProgram/Pages/OIGRiskAreaCompPlans.as
px) provides a discussion of the care planning process that can be used to ensure your systems are
meeting your care planning needs.
The documentation in the care plan must integrate data from the MDS, other assessments, and RAPs
to meet CMS requirements, including a description of the resident’s status in triggered RAP areas,
the facility’s rationale for deciding whether to proceed with care planning, and evidence that the
facility has considered the development of care-planning interventions for all RAPs triggered by the
MDS.
The following information is generally recommended for capture in a structured format with the
EHR or other HIT:
 Diagnosis or problem
 Measurable outcome/goal
 Actions or interventions/approach
 Rationale
 Progress
 Discipline
 Date
When a care conference is conducted, staff should be able to document a summary and all members
of the interdisciplinary team should sign the documentation. Again, such a sign-in sheet (identifying
date, attendee, and discipline or relationship to resident, such as self, relative, caregiver) may be fully
automated or generated by the system for signature and scanning back into the system.
Some HIT systems support narrative charting and summary development, therapy modules for
charting, and even picture-based support for certified nursing assistant (CNA) use at the point of
care. Wireless personal digital assistants (PDAs) or computers on wheels are often deployed for this
purpose.
Policy and Procedure Changes and Monitoring for Compliance
Whatever level of documentation the EHR or other HIT supports, the facility should use the
identified workflow and process changes to develop or update policies and procedures, as well as to
create or use monitoring tools to ensure completion of documentation, data quality, and compliance
with reminders and prompts.
Section 2 Plan—Implementation Strategies for Assessments - 3
Some EHR products for skilled nursing facilities provide a quality control dashboard for individual
users or a module that enables roll-up of information for monitoring purposes by the administrator
and managers. For the individual user, these may be displayed at log-in with resident-identifying
information and timing flags.
For administrators and managers, the system may support aggregate data in table and graphic form—
by nursing unit, nurse, or resident—of the following information:
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Census information
Incomplete clinical data and documentation, such as number of open admission assessments,
number of residents with no care plan updates within the past 72 hours, wounds with no
updates within the past week, etc.
Incidents, accidents, and injuries, such as number of falls, medication errors by type, etc.
Medication orders from the computerized physician order entry (CPOE) and medication
passes from the electronic medical administration record (EMAR).
Quality indicators, such as how many residents are on IV medications, those with behavioral
problems, those on oxygen, etc.
Minimum data set (MDS) warnings
Resources Utilization Groups (RUGS) and Medicaid case-mix scores
Clinical exceptions
Sentinel events
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Section 2 Plan—Implementation Strategies for Assessments - 4
Updated 03-19-2014