Beating the RAP (the latest survey pitfall).

In her last article, "Implementing MDS/Care Planning Software - Problems and Solutions," (NURSING HOMES, January/February 1994, p. 24), Marie Saunders offered guidelines to facilities for choosing and using clinical software. She also advised software shoppers to analyze a program according to how well it accommodates and facilitates the RAI steps. In this article, Ms. Saunders looks at recent survey problems with RAP Triggers and Guidelines, and whether software can provide solutions.

The scenario was all to familiar: an unexpected call describing a facility' s F270 citation, concerning the level A requirement for assessment. Despite medical records consistently showing a completed MDS that had been dated appropriately; a RAP Summary form indicating triggered RAPs with filled-in "Location of Information" (showing the care plan number for a "yes" decision to proceed, or a reference to an explanatory note for a "no") -- despite all this, according to the citation, the facility was not doing assessment at all!

Neighboring facilities had reported similar experiences, expressing puzzlement since similar records presented at the previous survey had resulted in no deficiencies. In fact, many had been praised for the quality of their recordkeeping.

Explanation: A Change in Priorities

The explanation does not relate to any change in the facility's assessment process, but rather, to a significant change in survey emphasis. Recent surveys have begun to focus on an area of documentation heretofore largely ignored within the Resident Assessment Instrument: the "location of information" documenting RAP Guidelines.

In May 1993, HCFA provided seminars to state surveyors in an "Advanced Minimum Data Set Training program." Two issue papers were part of the written training materials: "Use of Triggers and RAPS," and "RAI Policy Issues." Now used by surveyors in addition to the RAI Training Manual, these issue papers have become official policy and are being implemented through the survey process.

Understanding "Location of Information"

Since late summer 1993, surveyors have been paying closer attention to the RAP summary form, particularly "Location of Information." According to the RAI Manual, if a RAP is triggered, the following information MUST be referenced in that section:

Problems, complications and risk factors, need for referral to appropriate health professionals, and the reasons for deciding to proceed or not proceed to care planning.

An Example

Let's suppose Jon Jones takes Haldol and is exhibiting motor agitation. RAP #17 (Psychotropic Drug Use) is triggered because Jon's MDS indicates an antipsychotic drug (04a = 1-7) and motor agitation (H1c has been checked). Because of this, the medical record must now prove that the interdisciplinary assessment team has "worked" the RAP, i.e., identified the problem and performed additional assessment, as directed by the RAP Guidelines.

Working the RAPs

Now begins the process of going to the RAP Trigger Key and "matching" those Triggers that are true for Jon to the Guidelines. The Guidelines applying to Jon are general ones that always apply, regardless of the specific triggers, i.e. the staff must:

1. Perform drug review;

2. Review resident's conditions that affect drug metabolism and excretion; and

3. Review Behavior and Mood status, as well as

4. Review the guidelines listed under "Clarifying Information for Movement Disorder" -- the specific trigger (H1c) operating in this case.

Documenting "Location of Information"

Much of the information required for Jon may already be present in the chart. For example, in Guideline 1, Drug Review, the required "length of time...drug was first taken and onset of problem" may be in the nurses' progress notes or his psychiatrist' s consult report. "Doses of drug and how frequently taken" will be in his physician's orders and the medication administration record. "Number of classes of psychotropics" will be in the pharmacist's monthly drug review. And finally, "Reason drug prescribed" will be part of the physician's order.

If the data for Guidelines 2 and 3 and the clarifying information for movement disorder, as applied to Jon, are not already in the record, as well, a notation must be made to document them.

This information, along with all MDS and RAP summary forms, must remain in the active medical record for two years (though not necessarily all in the same binder). Thus, if a progress note is referenced as a "Location," that note must remain with the record for at least two years.

Surveyors are also checking closely the dating of the RAP summary form (it must be complete by the 14th day), with signatures of the RN coordinator and team members participating in the "RAP work."

Solving the Problem

Needless to say, this process of documenting "Location" is burdensome to the point where finding an alternative is essential. In light of this, consider a system that combines the assessment data required by the RAPs with the routine Assessment performed by the interdisciplinary team.

To do this, add appropriate RAP Guideline assessment data to each discipline's admission and annual assessment. Yes, this requires planning and an analysis by each discipline of all RAP-required data. The net assessment included in the RAI is much less than the sum of the RAP Guidelines. Many Guidelines are repeated in each RAP, and would be part of any good assessment. Asking the different disciplines to rewrite their assessments to include RAP information pertinent to their specialty will speed the process by eliminating duplication.

As things stand now, for instance, activities may assess fine motor skills and mobility, and then Nursing and/or Physical Therapy repeat the process. Not only is there a risk of recording conflicting and confusing data, but the duplicative effort is discouraging to everyone involved.

With a "comprehensive" system in place, all data can be pulled together in the same location. Because the MDS coordinator works with a medical record where each RAP guideline is documented in a consistent location, the RAP work is documented quickly and accurately.

Can Computers Expedite This?

All computerized MDSs will track triggering data and tabulate Triggers. But some programs, such as those providing only lists of potential and actual RAP triggers, indicate only that the triggers exist; they will not perform the further -- and vital -- step of indicating whether these variables are present in the combination that triggers the RAP. The user must still consult the RAP Trigger Key and "manually" go through the process of pulling this information together.

One facility I know of claimed that its software was triggering 12 RAPs, but when the information was pulled together in the appropriate combinations, they were in fact triggering only six RAPs. In short, they were doing twice the assessment work they needed to.

In the illustration we offered earlier, RAP #17 has separate Guidelines for each of the different combinations. Jon's facility will save time only if it has the vital information that, for him, only the four guidelines we mentioned earlier are required. And it will expedite recordkeeping to have Jon's information pulled together in one location. Both of these can be accomplished by appropriately designed software.

Marie Saunders, RN, BSN, is developer of the EnCompass computerized assessment and care planning system. She is Director of Saunders Associates, a long-term care consulting and software marketing firm in Appleton, WI (414/739-4653).