MDS Coordinator – Carolyn Pluta

This week’s spotlight is on Carolyn Pluta, OTR/L, CMAC, who now works as an MDS Coordinator for South Valley Post Acute Rehabilitation!

What is your full name, title, and company name for your current, primary role?

Carolyn Pluta, MS, OTR/L, CMAC. I am the MDS Coordinator for South Valley Post Acute Rehabilitation.

Where are you located?

Lakewood, Colorado

Where did you go to OT school, and what year did you graduate?

I went to OT school at Washington University in St. Louis. I graduated in 2014

What did you do when you first finished school, and for how long?

I immediately began my career as an OT with the Ensign Group in 2015, and have been with the company ever since! My first role was as a clinician in a SNF/LTC that primarily specialized in dementia care. I was with this facility for a little over two years before becoming a DOR for a sister facility.

In what setting(s) did you work, and what types of patients did you treat?

I have always worked in the SNF/LTC setting (and the occasional provision of outpatient services), with a primarily-geriatric population and a wide range of both acute and chronic conditions that have led to a functional decline. These conditions have included stroke, orthopedic injuries, dementia, infections (resulting in fall/failure to thrive), malnutrition, Parkinson’s, MS, spinal cord injury, TBI, substance abuse, cardiac conditions… the list goes on and on!

What did you enjoy about your early roles? What didn’t you enjoy?

I loved the creativity and holistic approach I could take with my profession, especially when it came to long term care! I have a huge soft spot for resident advocacy, particularly when it comes to progressive conditions such as Parkinson’s or dementia, and I loved (and still love) thinking outside the box to consider all factors in a resident’s care and realizing that OT can play a vital role in addressing more than just an obvious injury.

Wheelchair positioning, orthotics, and collaborating on wound prevention/care became some of my favorite areas. The hardest part for me when carrying on a full caseload was making sure I was always on my “A game” for my residents, families, and coworkers as I am an introvert at my core. I am someone who really likes to take my time with a task and it was hard for me to set time limits on each OT session then quickly switch gears to see the next patient. 

What else have you done since then, prior to your current role?

I was a director of rehabilitation for about three years for a sister facility, including during the onset of the pandemic. I was still a treating clinician for a portion of the day, but primarily held more of a management role that involved a lot more collaboration with the interdisciplinary team and overall development of the therapy program. 

When and why did you decide to do something non-clinical?

I always had non-clinical in the back of my mind while in OT school, but I just wasn’t sure what it would look like! For a while I had considered community OT in the form of women’s health, or even integrating yoga therapy.

I believe in the power of answering when opportunity comes knocking, and seeking mentorship/making connections along the way. As my career progressed in the SNF/LTC setting, I became aware of my preference to work “behind the scenes.” I realized that I did my best thinking alone rather than out loud, and that I depict my thoughts best when writing versus speaking.

I also started to appreciate the role that each discipline in the skilled nursing/long term care setting plays, rather than exclusively therapy, and being a DOR really sparked my curiosity of my fellow manager’s roles as we collaborated to achieve a common goal.

What are you doing these days?

I am an MDS coordinator (while still maintaining an active OT license)!

Are you still treating patients, or are you solely non-clinical?

I perform evaluations and the occasional treatment sessions for 1-3 patients a week, on average.

Typically, if someone admits over the weekend, or if caseload has really picked up, I am available to lend a hand (I have a very unconventional schedule of Saturday through Wednesday, so it helps being available as a therapist on the weekends).

How long have you been in your MDS coordinator role?

I started this MDS role in August of 2021.

Did you get any special certifications or training along the way to help you get into your current role?

I recently completed my CMAC (Certified MDS Assessment Coordinator) certification. I have also received mentorship and training through my MDS resource, as well as from other successful MDS coordinators in the company.

How did you find your job? Did you apply or find it through a connection?

I had expressed interest in an MDS coordinator position for quite some time to many supervisors and colleagues. It was pretty well known that I was pursuing this role, so I applied and interviewed for this position when the opportunity arose for an MDS coordinator at one of our new acquisitions. 

What are some of the things you did to stand out, take initiative, and advance in your career?

I would also recommend being honest with yourself about your strengths and preferences, and seek opportunities that are allowing you to express those attributes (perhaps even seek out creative ways in your current role to do so!).

While I was rehab director, I would begin to ask the MDS coordinator at our facility a lot of questions, and in general tried to learn more about the nursing side of long term care (the processes, documentation, and the rationale behind them). 

Since starting this role, I have become one of the first cluster lead MDS coordinators, meaning that I am available as a resource/mentor for other MDS coordinators in the region and help hold accountability to reach our goals each quarter.

Interested in a non-clinical career of your own, but don’t know where to start?

How have people reacted to you leaving patient care?

I have received support, some skepticism, and mostly curiosity as to how I could make this role work as a therapist rather than a nurse.

I think it was one of those things where I had to simply be given a chance, try it, and showcase my abilities versus trying to persuade or explain it to people.

Several people would ask why I would want to pursue MDS when “I’m so good” at being a DOR and/or OT, but I have come to realize that just because you are good at one thing doesn’t mean it is the best fit for you/what truly fuels you.

Various therapists I know have also inquired about it, as they too have entertained the idea of a non-clinical role and never before considered or heard of MDS.

What’s a typical day or week in the life like for you as an MDS coordinator?

My days consist of:

• Interdisciplinary meetings
• Creating new care plans and finding pertinent diagnoses for new admissions
• Setting assessment dates
• Care plan reviews for residents who have assessments or changes in condition
• Lots of chart reviewing or checking for updated physician progress notes
• Reviewing new physician orders
• Actual completion of MDSes and resident interviews
• Making sure restorative nursing programs are current, and reviewing them monthly with the restorative team
• Transmitting completed MDSes

The extent of each can vary each day based on deadlines and any needs in the actual facility. I also keep an eye on tracking our quality measures and collaborate with nursing to make sure we have systems in place to stay in good standing.

MDS is kind of the “spy” of the nursing home, in that we catch a lot of fine detail in documentation or diagnoses, so I also will notify departments of areas that need more attention or follow up as I come across them. 

What are some of the rewards of your role? What are the biggest challenges?

I love the sense of autonomy that this role provides. Since I am a one-person department, it is up to me to prioritize and schedule my days to make sure I am getting assessments done timely and thoroughly in a way that works for me.

I also enjoy the fact that while I am not supervising anyone, this role does involve a lot of interdisciplinary communication, delegation, and holding others accountable.

A challenge has been familiarizing myself with “nursing lingo” (ie., medications, wound classifications, etc) and learning to perform chart reviews with a different lens (much more focus on lab work, diagnosis specificities, medication administration records). I have truly enjoyed the growing pains, though. I would compare the process to that of learning a new language.

How did your clinical background prepare you for this role? Which skills transferred?

Therapists are wonderful at digging through charts and getting to the underlying “why’s” of a situation. This background has helped immensely with MDS and diagnosis coding. I have also applied my background from the good old “RUG-driven days” of skilled nursing, when therapists had to formulate a lot of the primary diagnoses for evaluations.

Therapists also have good awareness of changes in a resident’s condition, which has helped with determining if a new assessment is warranted. MDS coordinators work very closely with the rehab director, and my personal experience as both a clinician and a DOR has helped foster good collaboration in that regard, especially when it comes to case mix and PDPM (Medicare payment model).

I also feel that the lens of an OT/former DOR helps with care plan establishment, since we are very aware of the importance of seeing the full picture of a resident’s situation and needs.

My experience as an OT/DOR also gave me a good understanding of the importance of documentation and justifying everything. This is huge when it comes to MDS coding and care plans, as you need to support everything you code with concrete proof from the medical records within a certain time frame.

What type of person do you think would do well as an MDS coordinator?

This role requires someone to be detail-oriented, self-motivated, organized, thorough, and overly-communicative with other departments. There are a lot of processes to learn and it helps to be inquisitive and seek policies/resources in addition to mentorship.

Someone who operates with a “I don’t know the answer, but I’ll find out” mentality would do well! Since I am in my own department, I do not have anyone “helicoptering” over me to make sure I am doing my work. As a result, someone in this role needs to have good time management skills and ability to prioritize tasks for each day. 

Do you work remotely or onsite?

I work mostly onsite, with the occasional remote day if needed. It is important for me to communicate/collaborate in person with other department heads as well as know the residents personally.

On the other hand, there are days when I benefit from working remotely, especially if there are a lot of assessments due in a short time frame and I need the solo time to hyper-focus on that. 

Did you read any books, take any courses, or do anything special overall to get you where you are today?

I have sought mentorship from MDS coworkers in other facilities as well as MDS resources who have so graciously tolerated my never-ending questions and need for reassurance that I’m on the right track!

I scheduled my own individual meetings with mentors, and came prepared with lots of questions each time. I also have a print copy of the entire RAI manual and endless resources that I requested and were provided to me regarding ICD 10 coding, PDPM processes, case mix, and care plan establishment.

I’ve attended courses on ICD 10 coding and began to attend MDS meetings. I also requested MDS documents and powerpoints as soon as I knew I was interested in this role. In addition, I completed my CMAC, which consisted of courses for each component of MDS leading up to the final exam.

What is a typical career path for an MDS coordinator?

An MDS coordinator can be promoted to a resource or compliance position, or take a more flexible option as a float for multiple buildings in the same company. I also know quite a few MDS coordinators who have simply stayed with the same title because they enjoy it so much!

Then again, I am already an “atypical” MDS coordinator since I am an occupational therapist rather than an RN, so I like to think the path is what I make of it. Ensign has also just initiated the “Chief MDS Officer” role this year, which is given to an MDS coordinator that shows ownership for his/her building and the company as a whole.

What is next for you? What are your high-level career aspirations?

Truthfully, I would love to just continue to grow my proficiency in this role, especially since I am still a spring chicken!

There is always something new to learn and improve upon, and I am finding a lot of fulfillment in the current challenge. I also enjoy mentoring/teaching a lot, and I am fortunate to have recent opportunities to continue to do so as needed for new OT graduates in the long term care setting, as well as during MDS meetings.

My career aspirations are to be challenged, feel a sense of autonomy/creativity, and still have time and energy for my many Colorado hobbies. 🙂 I have begun to truly trust the process and know that if I enjoy what I do and work hard, the right opportunities will come. 

What career advice would you give yourself that you wish you had during school?