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June 15, 2004

Comments related to Activity Decision Tree RAP Process

1. I want to express an appreciation to CMS for attempting to make the RAPs more efficient and useful. It is important that the information on the RAPs be tied to the care plan, rather than being “busy work” that is mandated. Related to tying the RAPs and care plan together, CMS may need to look at the required time frames for completion. As a clinician in a SNF, my care plans were completed within 24-72 hours, long before the RAPs were even thought about. Completing the RAPs at 14-21 days did not help me generate a care plan, but was rather a task I completed because it was required.

2. Another compliment I would like to make is that I believe it is extremely important that the “Activity” RAP consider functional abilities (i.e. physical, cognitive, social and emotional functioning) and the impact of these on quality of life. This was not a requirement in the past RAP process for activities, but is in the new RAP. This is excellent.

3. On the proposed decision tree, there are a number of questions that duplicate questions already on the MDS (i.e. memory, communication, etc.). By duplicating questions and answers, the process is less efficient; however, if fields auto populated with answers from the MDS, this would reduce the duplication and extra effort.

Furthermore, this duplication could potential lead to conflicts and problems if one discipline says there is a problem in a functioning area and another does not. For example, the activity RAP could indicate a cognitive problem but the nursing RAP could not, and there might not be a diagnosis of cognitive deficits. This may lead to a care plan for cognitive impairment for one discipline and not others. While this may seem insignificant, state surveyors will pick up on conflicts like this within the care plan, and cite facilities for a lack of interdisciplinary care planning or inappropriate documentation. This needs to be considered as decisions are made about questions and auto population.

4. The format of a decision tree, or Sandy Fitzler’s proposed schematic, are both appropriate formats for the RAPs. The proposed schematic appears to be more of a visual illustration of the decision tree. Either is appropriate for the activity RAP.

5. Questions on the RAP need to be written in objective language, rather than calling for subjective judgments. The RAP is a clinical tool and should illustrate this in the language used. For example: question 1 “Does the resident have cognitive deficits…” is an objective question that can be verified with the Mini-Mental or other cognitive test; question 7: “Is is probable that the resident…” is a judgment statement and does not necessarily require facts to support answering this question. Rewording the question to be: “Are there any indications (i.e. verbal, behavioral, family communication) that indicate…” would be more appropriate and clinical while collecting facts, saving any judgments for decisions on care planning.

6. On the call, there was a suggestion that the RAP responses be written in layman’s terms. I would like to disagree with this statement. The RAP is a clinical tool that the clinician and interdisciplinary team are using to further expose potential problems. The current RAI manual states, “The RAPs are problem-oriented frameworks for additional assessment based on problem identification items” (Page 4-1). The RAI manual also states “Use the RAPs to analyze assessment findings and then ‘chart your thinking’ (Page 4-2). This clearly indicates that the intent of the RAP is for clinical purposes.

This clinical tool will lead to the development of a plan of care. The care plan is what should be written in layman’s terms so that any discipline, volunteer or family member can be involved in implementation regardless of their training or understanding of medical terminology. These individuals do not necessarily need to understand the RAP, only how to implement the plan of care.

7. Another suggestion on the call (and in the draft activity regulations and surveyor guidance) is the inclusion of interventions and modality ideas/suggestions. I would strongly discourage including these in the RAP process.

While it is nice to have a list of interventions/adaptations provided, CMS should not be prescribing interventions. As ATRA has indicated with other draft regulations, what CMS puts in writing is considered firm and law by providers, fiscal intermediaries and surveyors. If a clinician does not use these “prescribed interventions/adaptations”, there are surveyors who will cite the facility for substandard care.

In addition, by adding these into the RAPs and regulations, CMS is indirectly pointing out that there is a certain skill set required to provide and adapt activities for residents. This task should not be left to anyone but should be undertaken by professionals who are trained in adapting tasks. Qualified and trained clinicians should be performing the assessment, RAI process and development of the care plan. By including suggested interventions, CMS is removing clinical judgment and decision making from the hands of professionals and mandating specific interventions- whether this is intended or not.

8. Topics for Activity RAP ladders
The RAP on “Prefers Change in Routine” is appropriate for individuals who are cognitively intact and able to express themselves. The current status and language of this RAP is not appropriate or inclusive of individuals with cognitive or communication deficits. This RAP is extremely subjective, which is appropriate for quality of life issues; however, we must be careful that this does not turn into a satisfaction survey. Furthermore, with question 1 “Is the resident’s present daily routine dramatically different from the routine prior to admission?”, the answer will always be YES. When going from a community into an institutional setting, one’s life and routine are going to dramatically change. Therefore, is it necessary to ask this question? Or is there a way to reword it to make it more effective?

Thank you for the opportunity to participate in the webex call, and for this chance to offer comment on the development of the Activity Decision Tree RAP. Please let me know if you have any questions or if I can be of further assistance. Thank you.

Sincerely,

Dawn De Vries

Dawn De Vries, MPA, CTRS
ATRA Director of Continuing Education and Competency Training
Email: conferences@atra-tr.org
Phone: 703.683.9420