Harmony often receives questions during seminars, calls and emails wondering how to improve the CAA documentation in the SNF.
CMS has not set forth distinct mandates regarding the process for how nursing home staff uses the CAAs. For MDS 3.0 there are no specific tools mandated as long as the tools are current and founded on evidence-based or expert-endorsed research, clinical practice guidelines, and resources. The RAI process involves the completion of the MDS, the CAA's, and the development of a comprehensive care plan.
The CAA process functions as a decision facilitator on whether or not to proceed to care plan as well as to assess the resident in the areas that have been triggered with the use of evidence-based resources. The CAAs guide the assessor in determining the nature of the issue or condition and understanding the causes specific to the resident.
Documentation for each triggered CAA should describe:
- The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). What is the problem for this resident?
- Causes and contributing factors.
- Complications affecting or caused by the care area for this resident.
- Risk factors that arise because of the presence of the condition that affect the staff's decision to proceed to care planning.
- Factors that must be considered in developing individualized care plan interventions, including documentation to justify the decision to plan care or not to plan care for the individual resident.
- Need for referrals or further evaluation by appropriate health professionals.
- What research, resource, or assessment tools were used in performing the CAA. A source need only be cited if it is not already cited as the standard source used for this CAA by facility policy.
- Completion of Section V CAA Summary.