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This Q & A document contains question/response sets based on questions we received in the MDS 2.0 training concerning RAI Version 2.0. The number of questions we received indicates your interest and commitment to accurately using the MDS 2.0.
The document is formatted in a way that will allow easy use as a reference to answer MDS 2.0 questions and as a complement to the MDS Version 2.0 User's Manual. Refer to the Table of Contents for the sequencing and arrangement of questions/responses. Within each section of the MDS form, general questions are answered first followed by questions on specific sections in the order in which they appear on the MDS form.
This Q & A document for Version 2.0 is published by the NYS Department of Health and School of Public Health, University at Albany, SUNY. It may be copied freely, as our goal is to disseminate information broadly to facilitate accurate and effective resident assessment practices in long-term care facilities.
The Q & A was compiled by Barbara Page, RNC, MA, RAI Coordinator, NYS DOH; Janice Taylor, RN, MS, MDS Coordinator at Bishop Sherman Episcopal Nursing Home; and Dianne M. Zambori, RNC, BSN, CNA, DNS at UCP-Bayview Nursing Home. It was edited by Cheryl V. Reeves, MS, MLS, MDS Training Coordinator, School of Public Health, University at Albany, SUNY.
We would also like to thank Kathy Bettes and Bruce Salisbury for preparing this document for publication. We hope you will find the document as useful as we found the development effort.
Finally, we thank you for your continued enthusiasm in implementing MDS Version 2.0.
March 1998
POLICIES & GENERAL INFORMATION
CODING
Q. Directions state to enter code "NA" if information is unavailable. If computer does not accept "NA", what should I do?
A. The facility must contact the MDS 2.0 software vendor to insure that there is a provision for "NA" or "circled dash".
Q. We cannot determine highest level of education for many residents. How do we answer if no information is available?
A. Interview the resident and significant others and review the records. In situations where information is unavailable, use the standard codes "NA" or "circled dash". [Refer to User's Manual, page 3-19]
Q. Some residents are unable to tell you if they can see/hear, cannot be interviewed, and have no family or history available. How do you code these items?
A. Use your best clinical judgment. If information in unavailable use "circled dash" or "NA".
Q. Can "NA" be used in any section?
A. Yes. However, it must be used sparingly and judiciously.
Q. Some MDS items refer to status compared to 90 days ago. What if the resident's status fluctuated?
A. The 90 days refers to a fixed point in time, i.e. 90 days ago (or since the last assessment if less than 90 days). The comparison is between the current assessment and either of the above, not for periods in between.
Q. When the MDS 2.0 directs you to determine status 90 days ago, can you simply refer to the last MDS assessment?
A. These items refer to the status 90 days ago or since the last MDS assessment if less than 90 days. [User's Manual, page 3-104]
Q. User's Manual, page 2-25, states "Amendments may be made to any items during the next 7 day period..." Why can't you correct therapy time?
A. You may correct therapy time. [User's Manual, 2-25]
Q. What is the date that background information (Sections AB and A) must be completed?
A. Within 14 days. [User's Manual, 3-22]
Q. Resident is admitted on March 15. By what date must you complete MDS?
A. The MDS, Triggers and RAPs must be completed on or before the 14th day following admission. In this instance they must be completed by March 28.
Q. Please clarify the dating conventions for the Assessment Reference Date (A3a), the MDS Assessment Completion Date (R2), and the dates on the RAP Summary Form at Section V, B2 and Section V, B4.
A. The Assessment Reference Date (A3a) signifies the end of the observation period for all assessment items. For example, for an MDS item with a seven-day period of observation, assessment information is collected for seven days prior to and ending at the date at A3a. For a 14-day assessment item, the observation period is the 14 days prior to and ending at the date at A3a. The Assessment Reference Date is the common date for which all observation periods end. The Assessment Reference Date can be no later than 14 days after admission.
A3a and R2 are independent of each other. The period of time between A3a and R2 is the time during which staff members actually complete the MDS form. This activity is completed by the date at R2, which can be no later than 14 days after admission. The statute allows for the Assessment Reference Date (A3a) to be the same as the MDS Assessment Completion Date (R2). It may be more practical, although it is not a federal requirement, to leave some time between the dates at A3a and R2.
It would not make sense for the dates at R2 to precede the date at A3a, as this would indicate the MDS form was completed before the observation period has ended. Remember that the date at R2b is the date on which the RN Coordinator is certifying the MDS as being complete, which is a statutory responsibility. Signatures and dates at R2c-h indicate that other staff members have accurately completed particular sections of the MDS. Therefore, the date at R2b should be on or after the latest date at R2c-h. In any event, dates at R2b-h can be no later than 14 days following admission. Staff members still have until the 14th day to complete the RAP portion of the assessment.
The date at Section V, B2 on the RAP Summary Form indicates that the RN Coordinator is certifying that the RAP review is complete. The date at V.B2 can be no later than the 14th day after admission. This date can be used to determine the due dates of subsequent assessments. The date at Section V, B4 is the date that the care planning information required in column (b) of the RAP Summary Form is complete. This column provides information on final care planning decisions for all RAP clinical conditions and may be completed by any professional staff member. (That is, it does not need to be completed by the RN Coordinator.) It is completed after the interdisciplinary team has met and developed or revised the resident's care plan, incorporating the findings from that particular assessment. The date at V.B4 can be no later than seven days after the date at V.B2, as federal regulation requires the care plan to be completed within seven days of RAI (MDS and RAPs) completion. Refer to the User's Manual, pages 2-17 & 18, 2-28 & 29, and 3-29.
Q. If a resident is discharged on the 14th day, would the facility still be required to complete the entire MDS?
A. No. Refer to the User's Manual, page 2-6. Keep in mind, however, that evidence of assessment and care planning to meet the resident's needs should be in place, showing they have been initiated on or shortly after admission.
Q. If a resident enters the facility and does not stay at least seven days, is it necessary to begin an MDS?
A. No. The MDS/RAI does not need to be completed, either in part or in entirety, unless the resident has been in the facility 14 days or longer. [User's Manual, 2-4]
Q. Is there a list of which portions of the MDS each interdisciplinary team member fills out? What sections do you recommend rehab fill out? Who usually does the psycho-social section?
A. There is no recommendation for assignment of sections. Each facility should develop a policy assigning responsibility for completing sections of the MDS to staff members who have clinical knowledge of the resident and for whom the sections are within their scope of practice. [User's Manual, pages 2-16 to 2-17]
Q. Is it better for one person to complete the MDS because of consistency?
A. The RAI is best completed by an interdisciplinary team. [User's Manual, 2-16 to 2-17]
Q. Can only RNs complete sections?
A. No. Facility has flexibility in assigning sections to appropriate personnel. The RN Coordinator must sign the RAP Summary Form to signify completion of the RAI assessment. [User's Manual, 2-16 to 2-17]
Q. If you have an LPN as nurse manager responsible for the care plans and care of residents, can she/he complete the MDS 2.0 form and sign if co-signed by RN other than nursing rehab?
A. No. In accordance with the state's Nurse Practice Act, it is not within the scope of practice of an LPN to apply RAPs or develop resident care plans. Only an RN may do this. LPNs may complete those portions of the MDS which they are competent to do and may attest to the accuracy of the responses. Co-signatures are not required on the MDS.
Q. Can a PTA fill out all their MDS section and sign the back?
A. See DOH Memo 94-30 dated 10/18/94 and User's Manual, page 3-151.
Q. If we have regularly assigned sections for each discipline, can we write ?SS? or ?DTY? under the sections instead of the actual sections done?
A. No. Enter letters that correspond to sections of the MDS. [User's Manual, 3-167]
Q. When the RN Coordinator completes sections of the MDS, does she/he need to indicate those sections and sign under "Other Signatures" in Section R? Or can it be assumed that the RN Coordinator who signs at Item R2a and dates Item R2b is the person who completed any sections not signed for by anyone else?
A. The RN Coordinator must sign Item ADa when the Face Sheet is complete and Item R2a to certify that the MDS is complete. If the RN Coordinator completed sections of the MDS, signature at R2a is sufficient. It is assumed that the RN Coordinator completed any portions of the MDS that have not been designated by other staff. If the RN completing the MDS sections is not the Coordinator, that RN signs under R2c-h and the Coordinator signs at R2a. Federal regulations require each individual who completes a portion of the assessment to sign and certify its accuracy.
Q. Do all items on the MDS 2.0 need supportive documentation? What documentation sources can be used?
A. Some items are assessment tools in themselves. For example test for balance and customary routine questions require no further documentation. Other items such as rehab therapy or behavioral issues must be substantiated on the resident's record as determined by facility policy and in accordance with acceptable standards of practice.
Q. Does the facility need MDS 2.0 forms for record keeping or can it be done by computer?
A. The hard copy of the RAI need not be maintained if the entire clinical record is stored electronically and the additional conditions on page 2-19 of the User's Manual are met. The facility must be able to "produce" the completed form on request.
Q. Regarding User's Manual, pages 2-18 and 2-19, Electronic Clinical Record: Does this pertain to "paperless" facilities? If a facility is not completely automated and doesn't have the entire clinical record stored in the computer, does it have to have a paper MDS? RAI? If the MDS alone is in the computer, is a hard copy required?
A. Yes, the electronic clinical record refers to a "paperless" facility. Unless the entire clinical record is stored on computer, there must be a paper copy of the RAI including the MDS.
Q. How many MDS 2.0 forms should be left on the open medical record, especially with multiple ones being done with the Demo Project? Where are they stored?
A. Facilities are required to maintain 15 months of all assessment data in the resident's active clinical record. Storage is determined by facility policy. [User's Manual, 2-18]
Q. If you know you will be gone (e.g., on vacation) and you are trying to work ahead, can you look back four days instead of seven if you are doing it before Assessment Reference Date? Or should you have someone else do it so that they look back at all seven days?
A. Have someone else complete the assessment using the full observation period. The facility should establish a policy for accountability for completing the RAI. [User's Manual, page 2-18]
Q. Is Assessment Reference Date equal to "day 8" in scheduling MDS+ (for new admit and/or readmit)?
A. Yes. But this is not limited to "day 8". The facility determines the date, which can be any date up to the 14th day. [User's Manual, 3-29 and 3-30]
Q. Is the last day of observation period any day between the 8th and 14th day from admission?
A. It may be. Refer to User's Manual, page 3-29.
Q. Can the Assessment Reference Date (Item A3a) be the date the resident was admitted to the facility?
A. Yes. The date at A3a can be any date from admission until the 14th day following admission. When the admission date is used as the Assessment Reference Date, the assessment is based on information from an observation period that precedes the resident's stay (e.g., hospital records). [User's Manual, 3-29]
Q. The last day of the MDS observation period is March 1. I am doing MDS on March 3 and a behavior (or any issue) is exhibited/documented on March 2 and 3. How do I capture that on MDS?
A. Everyone must look at the same assessment time frame. Therefore you would not capture this behavior on the MDS. You would document your observation and care plan accordingly.
Q. What are the criteria for a readmission?
A. A readmission is defined as a return from a temporary absence for hospitalization or therapeutic leave (with the expectation of return). This is not tied to a facility's bed hold policy. The facility only needs to do a full assessment if a significant change has occurred. [User's Manual, 2-12]
Q. Resident was discharged for home and two days later returned. There was no bed hold; she was discharged. What assessment do we do?
A. Since return was not expected, do a full initial assessment. [User's Manual, 2-6 and 2-12]
Q. If the institutional policy for bed hold is 21 days and the resident returns on the 25th day after a hospitalization with no significant change, is a readmission or initial admission assessment done? It was anticipated that the resident would return to the facility.
A. Neither is required. Facilities are not required to assess a resident on readmission unless a significant change in the resident's condition has occurred. HCFA does not tie this to bed-hold policy. [User's Manual, 2-12]
Q. In my facility, without a bed hold, we consider a resident discharged. What assessment do we do if he/she comes back in 3 months? What are the time frames for readmits?
A. There is no time frame for readmissions. The determination to do a full assessment is based on whether or not there is expectation of return and/or a significant change in condition. [User's Manual, 2-12]
Q. Who decides significant change? Does it have to be a team decision?
A. No. Any member of the team with clinical expertise in that area can make the determination.
Q. Can the MDS Coordinator initiate the significant change assessment?
A. Yes.
Q. Regarding when a significant change assessment is not required (see User's Manual, page 2-11): Who makes the determination when a resident would not benefit from a reassessment?
A. Anyone competent to clinically assess the situation and make the determination.
Q. Once a determination has been made, do you have two weeks to implement approaches before starting the significant change assessment?
A. The amount of time that would be appropriate for a facility to monitor a resident depends on the clinical situation and severity of symptoms experienced by the resident. Generally, if the situation has not resolved within approximately two weeks, staff should begin a comprehensive RAI assessment. This time frame is not meant to be prescriptive but rather should be driven by clinical judgment and the resident's needs. [User's Manual, page 2-8]
Q. Does the staff have 14 days to decide if changes in the resident's status constitute a significant change? Once it is decided that a significant change has occurred, does the staff have 14 days to complete the significant change assessment?
A. A significant change assessment is not required in a case where the resident's condition is expected to return to baseline within a short period of time, for instance one to two weeks. If the condition does not return to baseline, the assessment should be completed as soon as needed to provide appropriate care to the individual. In no case should this be more than 14 days after the determination was made that the significant change occurred. Refer to pages 2-8 through 2-12 of the User's Manual for guidelines concerning significant change.
Q. For significant change assessments, do you count two changes within each quarter, within each year, or within each assessment period?
A. A significant change assessment is appropriate if there is a consistent pattern with either two or more areas of decline or two or more areas of improvement. Any determination about whether a resident has experienced a significant change in status is a clinical decision. [User's Manual, page 2-9]
Q. If discharge is planned "in the immediate future" but beyond 14 days and a resident's condition is stabilized, do you do a significant change? (No time frame for discharge is specified in User's Manual, page 2-11).
A. The exclusion criteria indicates a significant change is not necessary if the facility has engaged in discharge planning with the resident and family and a comprehensive assessment is not necessary to facilitate discharge planning.
Q. If a resident has one area of decline and one area of improvement, do you need to complete a significant change assessment?
A. No, a significant change assessment is appropriate if there is a consistent pattern of changes in two or more areas of decline or two or more areas of improvement.
Q. With significant changes, it is sometimes impossible to determine if the change is permanent. What if you do a significant change and then the resident gets better?
A. If resident improves in 2 or more areas, you do another significant change. [User's Manual, 2-9]
Q. Is a significant change assessment necessary if the resident has a new medical diagnosis (e.g., new onset seizures)?
A. It may. See definition on page 2-8 of the User's Manual.
Q. On User's Manual, page 2-9, "Guidelines for determining significant change on resident status": Are two of the bulleted items necessary for a significant change or only one? That is, does change in decision making without other changes require a significant change?
A. Each bullet on User's Manual, page 2-9, represents one example of a decline. Note that this is not an exhaustive list.
Q. If a resident develops a Stage 2 pressure ulcer and it heals in 10 days, is this a significant change?
A. Generally no. The facility will need to note the resident's condition in the clinical record and implement necessary clinical interventions. However, if the change in the resident is self-limiting and improves within two weeks, a significant change RAI would not be necessary. In this case, care plan changes such as interventions to prevent the recurrence of a pressure ulcer would be appropriate. Review the conditions of significant change on pages 2-8 through 2-12 of the User's Manual.
Q. If a Stage 2 pressure ulcer goes to a Stage 3 and no other changes are noted, is it a significant change?
A. No. [User's Manual, 2-8]
Q. Does an unplanned weight loss (e.g., 5% in 30 days or 10% in 180 days) require a significant change assessment if that is the only change? What if, at the time of the next scheduled assessment in three months, the resident hasn't regained the weight?
A. Generally weight gain would not require a significant change assessment unless there is a second area of decline. However, you should note the resident's condition in the clinical record and implement necessary clinical interventions. In this case, a discrete assessment in the area of nutritional status may provide evidence of the extent of the problem as well as information on which to base appropriate changes in the resident's care plan that will result in weight gain. However, if the problem persists or worsens, a comprehensive RAI reassessment may be clinically indicated. If the weight loss continued on the subsequent assessment, it would probably be appropriate for the facility to indicate why the desired change has not occurred and to modify the existing care plan. [User's Manual, 2-8 through 2-12]
Q. A resident has a 5% weight loss in 30 days and is not on a weight change plan. She/he begins to regain weight during the 14-day assessment period. Do we need to continue with the significant change, especially if the care plan already includes the problem "potential for weight loss"?
A. First, a 5% weight loss in 30 days does not generally require a significant change reassessment unless the weight loss is accompanied by a second area of decline. Second, as the resident has started to regain the weight (and assuming the appropriate care plan interventions are in place), it is probably sufficient to continue monitoring the resident's nutritional status and weight gain. You could delay conducting the comprehensive RAI reassessment unless it appears that the resident would benefit from an immediate reassessment and holistic revision of the care plan. Note that this answer assumes that the care plan has already been modified to actively treat the weight as opposed to continuing with the original problem, "potential for weight loss". This situation should be documented in the resident's clinical record along with the plan for subsequent monitoring. However, each resident situation is unique and the interdisciplinary treatment team must make the decision as to whether the resident will benefit from an RAI. [User's Manual, 2-8]
Q. How does fluid fluctuation related to gain/loss of edema with a medical cause fit into significant change requirement for weight gain/loss?
A. A significant change assessment requires two changes. If this loss is an established predictable pattern, this would not be a significant change. Refer to User's Manual, page 2-11 for exclusion criteria.
Q. If there is a significant weight change any time within the time frame of 30 days or 180 days, should we do a significant change (assuming there is another area of decine)? Or should we compare present weight with weight at exactly 30 or 180 days only?
A. Compare to weight of either 30 or 180 days ago. [User's Manual, 3-128]
Q. Is there a specific amount (in pounds) of weight gain/loss that we have to address?
A. No, the weight changes are calculated in % of the resident's weight; therefore, it will be different for each resident.
Q. Resident admitted to facility with poor appetite. During the initial assessment, potential to lose weight was discussed and documented. After 30 days, weight loss is 10 pounds. Does this require significant change if there is no other change in health status?
A. Because there is only one area of change, a significant change assessment is not required. However, staff members may decide a full assessment is warranted depending upon the percentage of loss and their clinical judgment. [User's Manual, 2-8 to 2-9]
Q. A resident lost 5% of weight in 1 month and has a new stage 3 pressure ulcer. Is this a significant change?
A. Yes. [User's Manual, 2-9]
Q. If significant weight loss occurs in a resident in the facility for short-term rehab (three months or less), do we have to do a significant change assessment (as per page 11 in workbook, "stabilized resident who is expected to be discharged in immediate future")?
A. Weight loss alone does not require significant change assessment. If resident is not due to be discharged for three months and experiences two decreases or increases in status, you would complete a significant change assessment.
Q. A resident falls and fractures a hip, attends rehab, and completes a course of treatment back to independence. Because the resident is staying in facility, is this considered significant change?
A. Yes, if it meets the criteria. [User's Manual, 3-37]
Q. If a resident is on a restorative program and makes the expected gains in ADLs in three categories, is another MDS required?
A. Yes. [User's Manual, page 2-10]
Q. For a resident on rehab, we set a goal for increased independence in transfer and ambulation. If the resident improves, does this require a significant change assessment?
A. Yes, a change in two or more ADLs (in this case, transfer and ambulation) requires a significant change assessment. [User's Manual, 2-9]
Q. For significant change in ADLs, MDS+ directed us to look at decline or improvement in two or more ADLs over time as significant change. New MDS 2.0 wording states when resident is newly coded as "3", "4" or "8". Do we no longer look at significant change over time or subtle change when coding is changed at lower level than "3" or "4" (i.e., "1" to "2")?
A. No. Refer to 2-9 in the User's Manual, but note that this is not an exhaustive list.
Q. Is decline in ADLs with decline in communication no longer an indicator?
A. A significant change assessment must be done for a decline in two or more areas. ADLs alone might involve two areas of decline. ADLs and communication would be two areas.
Q. Resident entered nursing home for rehab for a fractured hip. Initial assessment showed her requiring extensive assist in ADLs, and she was rehabilitated to a minimal assist. Other areas remained unchanged. Would that fall under steady progress for a significant change?
A. Any improvement in any ADL physical functioning area (coded "0", "1", or "2" when previously coded "3", "4", or "8" on G1a) meets criteria for one area of increase. Improvement in two ADLs would constitute a significant change. [User's Manual, 2-10]
Q. If you locate an error after MDS 2.0 is input and transmitted to the state, how do you correct it if only one section (e.g., advance directives) is inaccurate?
A. Minor changes should be documented in medical record. Major changes would require a new full assessment. [User's Manual, page 3-11]
Q. What would constitute a "significant correction of prior assessment". Do you only reflect the correct answer on a significant correction of prior assessment?
A. The facility would determine if the error meets the criteria for a significant correction of prior assessment. In that case you must complete a new full assessment. The Reason for Assessment (Item 8a) would be "4, Significant correction of prior assessment". Also code Item 3b according to the number of corrected assessments (for that particular annual, etc.). [User's Manual, 2-27]
Q. If one discipline (e.g., activities) completes MDS incorrectly and this meets the criteria for significant change of prior assessment, does the entire form need to be redone?
A. Yes. [User's Manual, 2-25]
Q. What do you do when an MDS has been scored by two different staff members from one assessment to the next and, due to a variance in interpreting how to score the assessment, it looks as if a significant change has occurred when it has not?
A. Complete a "significant correction of prior assessment" (code Item A8a = "4"). Reassess the resident by completing a new MDS and RAP Summary Form and revise the care plan if appropriate. Adherence to item definitions and instructions, as well as to the requirements for completion of the assessment (e.g., interview direct care staff across all 3 shifts), should result in high rates of inter-rater reliability for MDS items. Variance in scoring the same resident by different staff members may indicate a need for staff education on how to complete the MDS. [User's Manual, page 3-11]
Q. What is the time frame allowed to submit a significant correction of prior assessment?
A. The intent is to complete and submit assessment as soon as possible. [User's Manual, 2-27]
Q. Can a significant correction of prior assessment be performed on a quarterly review or only on a full assessment?
A. A significant correction of prior assessment may be necessary for a quarterly review assessment and a new "Reason for Assessment" (record type) has been created to allow for this. In the near future, HCFA will publish a revised MDS form along with record data specifications and information regarding the anticipated effective date. It will be available to software vendors on HCFA?s World Wide Web site. On the revised form, Items AA8a4 and A8a4 will be relabeled "Significant correction of prior full assessment". New Items, AA8a10 and A8a10 will be added and labeled "Significant correction of prior quarterly assessment".
Q. If, during the quarterly review, you find the last full assessment was wrong, do you code quarterly review or significant change?
A. Code Section AA8a "5" for quarterly review on the Basic Assessment Tracking Form which is completed along with the quarterly review assessment. Determine if inaccuracies in the last full assessment are such that a comprehensive reassessment is appropriate. (Refer to the User's Manual, pages 2-26 and 2-27, for guidelines concerning when a significant correction assessment is appropriate.) If you determine that a reassessment is necessary and the quarterly review has not been completed, you do not need to complete the quarterly review. Instead initiate a full assessment. Code Item A8 (Reason for Assessment) as a "4, significant correction of prior full assessment". This signifies that the resident's status is significantly different from the previous assessment as opposed to the resident having experienced a significant change in status. This process will identify your initiation of the required quarterly review assessment and your identification of significant inaccuracies requiring a reassessment.
Q. The Quarterly Assessment Form, Discharge and Reentry Tracking Forms have not arrived at our facility. Are we expected to go back to January 1 for all residents, or do we start from day the forms arrive?
A. All assessments on or after January 1, 1998 must be done using the relevant MDS 2.0 forms (Full Assessment, Quarterly, Discharge/Reentry Tracking Forms).
Q. How are signatures obtained when using a computerized version of 2.0? Hard copy printed and signed?
A. This is software specific. You need to check with your vendor.
Q. If you put multiple answers (i.e., handwritten comments) on the MDS, how does it get entered into the computer?
A. Written comments are for facility purposes only and not part of MDS 2.0 database.
Q. The top of each page of the MDS form contains the wording "Numeric Identifier" followed by a blank line. What is this used for?
A. This is an optional item the facility may use to identify a resident as it gathers information on the MDS. In a paper environment where pages may be separated, this item could aid the facility in gathering the form together. See the example shown on pages 4-24 through 4-30 in the User's Manual. This is not a HCFA or state requirement.
Q. Are facilities required to complete the Basic Assessment Tracking Form (Section AA) for all scheduled assessments?
A. Yes. A paper or hard copy of the Basic Assessment Form must be completed for each full, quarterly, or Medicare assessment, effective as of the date of MDS 2.0 implementation. [User's Manual, page 3-1]
Q. What is the purpose of the Basic Assessment Tracking Form?
A. The Basic Assessment Tracking Form identifies the resident in a computerized environment. The Discharge and Reentry Tracking Forms provide key information to identify and track the movement of residents in and out of the facility.
Q. What are the time frames for completion of tracking forms?
A. The Basic Assessment Tracking Form must be completed within the same time frame as the required assessment (e.g., within 14 days after admission). The Discharge Tracking Form must be completed within seven days of discharge. The Reentry Tracking Form must be completed within seven days of return to facility. In New York State these forms must be submitted electronically within four weeks.
Q. Are all of the tracking forms to be kept on the medical record for 15 months?
A. All tracking forms must be maintained in the active clinical record along with the required 15 months of RAI information. [User's Manual, 2-18]
Q. What are the qualifications for "Title" as requested in Section AA, Item 9 on Reentry Tracking Form?and Discharge Tracking Form? Can clerical staff complete this, or is a professional required to complete these sections?
A. Clerical staff may complete these items. The assignments of who completes portions of the assessment are determined by facility policy in accordance with scope of practice. [User's Manual, pages 2-17 and 3-2]
Q. Is a Discharge Tracking Form completed if a resident is discharged to the hospital with a bed hold? When is Reentry Tracking Form completed?
A. Complete the Discharge Tracking Form and Reentry Tracking Form based on admission to hospital, regardless of whether or not there is a bed hold. The Reentry Tracking Form is completed whenever a resident reenters the nursing home following temporary admission to a hospital or other health care setting. [User's Manual, 3-2]
Q. If someone does not pay for the bed hold and you expect them to return, should you put "discharge return anticipated" (Item 8a = "7") on the Discharge Tracking Form?
A. Yes.
Q. Must we fill out a Discharge Tracking Form for residents who go out for dialysis treatments? What if the resident leaves for dialysis in early evening or late afternoon and returns to the facility after midnight (technically a different day)?
A. No, not unless resident is out 24 hours or more. [User's Manual, 3-2]
Q. Does the Discharge Tracking Form apply to outpatient or 23-hour observation stays when the resident is not actually discharged from the facility?
A. No. The Discharge Tracking Form is completed only when the resident is out of the facility for an overnight stay except for a temporary visit home. This applies regardless of the facility's policy and procedure for discharge or opening and closing records.
Q. A resident is discharged to the hospital. Discharge Tracking Form is filled out for hospital admission. Section AA, Item 8 is answered "7, discharged--return anticipated". Three days later the resident dies in the hospital. Do you then fill out another Discharge Tracking Form making the answer to Item AA8 a "6, discharged--return not anticipated"?
A. Yes. The second Discharge Tracking Form removes the resident from the system. [User's Manual, 3-2]
Q. How long is a "temporary hospitalization"? We have residents who sometimes go the hospital for 3 weeks, usually without significant change on return.
A. The term "temporary hospitalization" is not used.
Q. Resident had a bed loss and the record was closed. The resident is then readmitted. Are the Sections AB, AC & AD redone?
A. No. Background (Face Sheet) is required if the person is re-entering the facility after a discharge where return had not been previously expected.
Q. For Item AA7, is the Medicaid number intended to capture the case number or the recipient number?
A. The number in Item AA7 is the Medicaid Recipient Number. This is an eight-digit code that tracks the person across all provider types. The Recipient Number is a unique identifier number assigned by the state Medicaid office. Questions regarding the Medicaid number can be referred to the state Medicaid office.
Q. For zip codes (Item AB4) what do you use for residents with no known social history prior to living in an adult home?
A. Use previous adult home zip code. [Refer to User's Manual, page 3-17]
Q. What zip code do we use for an infant?
A. If the child never lived at home, use the zip code of the hospital where he/she was born. If the child went home from the hospital, use the zip code of the parents.
Q. Under mental health history (Item AB9), is depression considered a psychiatric disorder?
A. Depression may be coded here as a psychiatric disorder if the qualifiers on page 3-21 in the User's Manual are met.
Q. How do you code A3b if the assessment you are doing is the original? ...the first corrected copy, etc.?
A. If this is the original assessment code "0". If it is the first significant "correction of a prior assessment", code accordingly as "1". If it?is the second correction, code "2", etc. [User's Manual, 3-31]
Q. Please define Item A7h (Medicaid resident liability or Medicare co-payment).
A. This is the beneficiary's liability for PART A co-insurance. If the resident or family is responsible for the co-pay, A7h should be checked. Medicaid liability is the applied income (e.g., pension, Social Security funds, referred to as Net Available Monthly Income or NAMI) that is paid to the nursing home.
Q. Item A7 states "check all that apply in the last 30 days". On a new admit do you go back 30 days? Do you need to know hospital insurance coverage (or just since admission date to nursing home)?
A. No. The current payment source(s) are for the nursing home stay as indicated on the MDS 2.0 form. [User's Manual, 3-32]
Q. In Item A8, Reason for Assessment: Why would we check "6", "7", "8", or "9" when the manual states, "This is not a code used on this form..."?
A. There must always be an answer in ItemA8a. Use either "1", "2", "3", "4", "5", "8", or "0".
Q. Responsibility/Legal Guardian (A9): If resident does not have anyone listed and cannot make his/her own decision, do you use "i = None of the above"?
A. Yes.
Q. What is a good way to test cognitive status?
A. Refer to pages 3-41 to 3-45 in User's Manual.
Q. How do you accurately assess cognitive status for an aphasic resident?
A. It is often difficult to accurately assess cognitive function (ability to think, remember, and make decisions about daily lives) for people who are unable to verbally communicate with you. It is particularly difficult when the areas of cognitive function you want to assess require some kind of verbal response (e.g., memory recall). It is certainly easier to perform an evaluation when you can converse with residents and hear responses from them that give you clues to how they are able to think (judgment), if they understand their strengths and weaknesses (insight), if they are repetitive (memory), or if they have difficulty finding the right words to tell you what they want to say (aphasia).
To assess aphasic residents it is very important that you hone your listening and observation skills to look for non-verbal cues to their abilities. For example, for residents who are unable to speak but seem to understand what you are saying (expressive aphasia), you could ask the necessary questions and have them answer with whatever non-verbal means they are able to use (e.g., writing the answer; showing you the way to their room; pointing to a calendar to show you what month/season it is). Observe the residents at different times of the day and in different types of activities for clues to functional abilities. Solicit input from the observations of others who care for the residents.
In all cases code the cognitive items with answers that reflect your best clinical judgment, realizing the difficulty in assessing residents who are unable to communicate. Items B1, B4, B5, and B6 can be successfully coded without having to get verbal answers from the resident. Interdisciplinary collaboration will be helpful in conducting an accurate assessment. [User's Manual, pages 3-44 and 3-48]
Q. The User's Manual on page 3-49 makes reference to the MDS Cognitive Performance Scale. Where can we get copies?
A. This scale appears in the Appendices of several versions of the User's Manual.
Q. Can you define comatose and persistent vegetative state (PVS) more clearly?
A. Coma and PVS describe states of consciousness. Consciousness encompasses degree of arousal and degree of awareness. Arousal is a measure of being awake. Awareness involves interpretation of sensory input and giving an appropriate response. When a resident is comatose, he/she cannot be aroused, is unaware of incoming sensory stimuli, and is not able to respond actively. In a persistent vegetative state, a person arouses, not in response to external stimuli, but has no awareness.
Q. Do we need an MD diagnosis of coma or vegetative state?
A. Yes. In New York, a physician, nurse practitioner, or physician's assistant may make this diagnosis.
Q. With children who have MR/DD and no speech, do you score memory (Item B2) as "1" or "NA"?
A. The User's Manual, pages 3-42 and 3-43 states, "If there is no positive indication of memory ability, the correct response is '1, Memory problem'".
Q. If a resident is non-English speaking, how do we accurately code Items C4 and C6?
A. See User's Manual, pages 3-52 to 3-54.
Q. How do you assess vision on a cognitively-impaired resident?
A. Refer to page 3-56 in the User's Manual.
Q. Are intraocular lens implants (IOLs) documented under Section D, Vision Patterns?
A. Section D of the original MDS+ was revised so that lens implants are no longer captured in Version 2.0. The presence of an intraocular lens implant should still be included in the resident's physical assessment and documented elsewhere in the resident's clinical record.
Q. What should be coded under Item E1 if you have a dementia resident who repeatedly asks "what do I do" or "where do I go" and does this because of dementia and not depression or sadness?
A. The resident's actual behavior, regardless of the assumed cause, is to be coded as described. [User's Manual, page 3-60]
Q. What are the criteria for determining if mood or behavior are easily altered (Items E2 and E4)? Does this include results that are brief or temporary?
A. Criteria for determining mood alterability are explained in the User's Manual, page 3-60. Criteria for behavior alterability appear on page 3-65. You should code these objectively even if the results are brief. Then document in progress notes or CCP.
Q. Do you need daily documentation for behavioral symptoms (Item E4)?
A. Refer to User's Manual, page 3-64, for documentation guidelines. There should be notes in the resident's record to support quantifiable responses on the MDS 2.0. Facility policy would determine how this is accomplished.
Q. Is there a time frame for refusing to eat or to take meds (Item E4e)?
A. Yes. Refer to User's Manual, page 3-65, for the coding directions.
Q. "Combative Behavior" vs. "Resisting ADLs": Where is the line? If a resident pushes care giver away, is this combative or resistive?
A. Combative behavior infers a physical striking out with force at another person or object. Examples would be punching a wall or striking an individual. Clinical judgment must be used in determining resistive versus combative acting out.
Q. Should the response to Item E4e (Resists Care) include instances where the resident exercises his/her right to refuse treatment?
A. No. This item includes resistance to taking medication/injections, ADL assistance, or help with eating. This category does not include instances where the resident has made an informed choice not to follow a course of care (e.g., resident has exercised his or her right to refuse treatment and reacts negatively as staff members try to re-institute treatment). [User's Manual, 3-63]
Q. I have a resident who will not open her eyes, will not move, and does not acknowledge the nurse. Is this considered resisting care?
A. No.
Q. Item E5 asks for a comparison to behavioral status 90 days ago. Does this comparison include the entire 90-day period or a snapshot of today versus a one-day snapshot of 90 days ago?
A. Item E5 asks for a snapshot of today as compared to 90 days ago (i.e., a comparison of two points in time). The intent of the item is to document whether the behavioral symptoms or resistance to care exhibited by the resident remained stable, increased, or decreased in frequency of occurrence or alterability as compared to the resident's status of 90 days ago. By definition, this refers to the status (new onset, improvement, worsening) of any of the symptoms described in Item E4. If the resident is a new admission to the facility, review changes in the period prior to admission and score the resident at the time of the observation period as compared to the resident's status 90 days ago. Behavioral symptoms for the entire 90-day period should be reviewed, however, for care planning purposes. [User's Manual, pages 3-66 through 3-68]
Q. If B4 (Cognitive Skills for Daily Decision-making) is "0 - Independent", would Item F1d (Establishes own goals) also be checked. There are no qualifiers for "establishes own goals".
A. Generally that would be true. See User's Manual, page 3-69 for examples.
Q. Regarding Items F2 and F3, the guidelines in the User's Manual on page 3-70 (process paragraph) state to observe "over the past seven days". This was not stated for Item F1. The observation periods for Items F1, 2, and 3 are not noted on the MDS. Please clarify the expected observation period for F1.
A. Items for which observation periods are not specifically listed on the MDS are always seven days. Use "over the past seven days" as the observation period for F1. This is stated in the "process" paragraph, User's Manual, page 3-29.
G1. ADL (Self-Performance; Support Provided)
Q. In areas that have 2 columns, do you always complete column A first, then column B based upon decision for column A? (Example: Items G1a-j, Items G4)
A. Column A should be completed first. Research has shown this method increases reliability of the item. It must reflect what the resident actually does. For Item G1, Column B (Support Provided) is not based on the response in A. It is coded capturing the maximum amount of support for resident.
Q. Regarding the concept of weight-bearing support in Item G1A (ADL Self-Performance), code "3, Extensive Assistance": Does weight-bearing support refer to staff taking some of the resident's "weight"?
A. Yes.
Q. Please explain the intent of code "8", particularly regarding walking and eating.
A. Code "8" is used when an ADL did not occur in the seven-day observation period. For example, use code "8" for both the self-performance and the support columns when a resident did not walk in the past seven days (in room/in corridor). Refer to the guidelines, definitions, and examples in the User's Manual beginning on page 3-73.
The eating item (G1h) is a little more complex. If, in the past seven days, the resident truly did not receive any nourishment, the item would be coded "8". It should go without saying that this is a serious issue. Be careful not to confuse total dependence in eating (code "4") with the activity itself (in this case, receiving nourishment and fluids). G1h includes receiving IV fluids. For a resident who is receiving fluids for hydration and is totally dependent, this is coded as "4", rather than "8". Keep in mind that a resident who is fed via tube and manages the tube feeding independently is coded as "0 - independent".
Q. If resident can turn and position self in bed but cannot move to sitting position, what is his/her score on Item G1a?
A. This resident could be coded as a "2" or "3". However, more information is required to make a determination. [User's Manual, 3-73 through 3-77]
Q. On MDS+, if a resident was only OOB on a stretcher for a bath, the answer for transfer was "did not occur". Would Item G1b (Transfer) be an "8" now?
A. Code as an "8". Also refer to Item G6 on the MDS 2.0.
Q. For Item G1b (Transfers) is a Sarah Lift considered "extensive assistance" or "total dependence" since resident does bear weight? How is a resident's self performance coded?
A. This should be coded as a "3, Extensive Assistance". [User's Manual, 3-78]
Q. How should Items G1c and d (locomotion on and off the unit) be coded for a resident who propels his wheelchair but does not make it to a destination without help?
A. Code the items according to the amount and frequency of assistance received, using the ADL Self-Performance and Support code instructions provided in the User's Manual, pages 3-73 through 3-89.
Q. Should nursing put an ADL score for ambulation in hall (G1d) if resident refuses to ambulate for nursing but ambulates in the hall daily for O.T. staff.
A. Yes. The issue is whether or not the resident walks in the corridor on the unit.
Q. If a resident is bed bound and does not walk, do you code as an "8"?
A. Assuming this question is in reference to Items G1e and G1f (locomotion on and off the unit), the User's Manual reference for this response begins on page 3-73. If the resident is bed bound and does not walk and there was no locomotion via bed, wheelchair, or other means, then you code as "8". However, if the bed is moved in order to provide locomotion on or off the unit, then you would code according to the definitions provided in Items G1(A) & (B). If this question refers to G1c and 1d (walk in room/corridor), code as an "8".
Q. If a resident needs assistance every day to dress only lower limbs, is resident coded as a "4" in self performance on Item G1g (Dressing)?
A. No. Resident may be coded as a "2" or "3" depending upon the type of assistance he/she received during the last seven days. [User's Manual, 3-77 and 3-78]
Q. For Item G1i (Toilet Use) do you code for self performance and assistance needed for incontinent residents who have their Attends changed in bed, or do you put "8"? What about a resident who is completely incontinent of urine and stool and is never put on commode or toilet pan?
A. In both cases, code self performance as a "4". [User's Manual, 3-74]
Q. On page 3-75 in the User's Manual, does the example given about toileting (end of next to last paragraph) contradict self-support guidelines for ADLs?
A. No, it is consistent with the coding guidelines.
G3. Test for Balance
Q. Is standing balance coded for standing only? How is the item coded for residents who can stand but cannot get to a standing position without physical assistance?
A. As the User's Manual states on page 3-91, "DO NOT attempt to test residents who cannot stand by themselves. Code these residents a '3, not able to attempt test without physical help'".
Q. For the resident with tentative steppage, Parkinson-type movement, or Tardive Dyskenesic movements, how do you do the balance tests (especially if they can ambulate with devices)?
A. Residents who cannot stand by themselves should not be tested. [User's Manual, 3-91]
Q. Test #3 of the test for balance is a significant concern for any hip fracture or total joint replacement. Total hip precautions prevent crossing midline. Heel to toe is exactly at midline, but as a PT, I would not ask an 85-year-old resident with a hip fracture to do this. If personnel who are not aware of hip precautions perform this test, you may have a real physical problem and a liability issue on your hands. You really should eliminate hip fractures and THR?s from this test.
A. It stands to reason that a resident with a hip fracture or total hip replacement should not be tested for balance. It is the responsibility of the interdisciplinary team to communicate all precautions surrounding care of the residents and to assure the precautions are followed.
Q. Do you only test balance for residents who do not have an appliance?
A. No. Residents who use devices are tested without devices (except for a prosthesis), but only if the resident can stand by themselves.
Q. If a person is unable to comprehend the test for balance directions but is fully ambulatory, how would you score them?
A. Code as a "2". [User's Manual, 3-92]
Q. If resident successfully completes parallel stand test but is unable to successfully complete 2nd position (i.e., needs support), how is this coded?
A. Code as a "2". [User's Manual, 3-92]
Q. During the third part of the standing balance test (one foot in front of the other), you notice residents bend at the knee, trying to keep their balance. Do you want them to straighten their knees and lose balance? (Their center of gravity changes.)
A. No. Code as "1". [User's Manual, 3-92]
Q. If a resident has a weight bearing status of NWB, TTWB, or PWB, would we document N/A or "3" for standing balance?
A. This resident would be coded as a "3". [User's Manual, 3-91]
Q. Should resident be in bare feet when testing balance?
A. The resident may be tested using footwear or in bare feet, depending on what makes the resident most comfortable and assists with his/her balance.
Q. Does balance test need to be performed on all seven days?
A. No, the test should be conducted once on a day/time when the resident is at his/her best.
Q. May we use a wheelchair with foot rests and removable armrests for sitting test for balance?
A. No. [User's Manual, 3-94]
Q. Can an OTA or PTA assistant perform these tests (balance, ROM)?
A. Yes. They are screening tests to determine the need for in-depth therapy evaluation.
Q. Can a CNA or rehab aide do balance test or range of motion test?
A. No, a clinician must conduct the test as it is not within the scope of practice for a CNA.
G4. Functional Limitation in Range of Motion
Q. There is no longer a question on contractures. We are presently doing contracture assessments quarterly. Is this still necessary?
A. Item G4, Functional Limitation in Range of Motion, has replaced the MDS+ item on contractures. It is a quarterly item. Each resident's range of motion and voluntary movement must be assessed during the identified observation period for all resident assessments. It is the responsibility of each facility to determine who will conduct this screening test in keeping with the health professional's scope of practice.
Q. If a resident is limited in ROM on one or both sides (coded "1" or "2") but this does not interfere with his/her ADLs, shouldn't it be scored "0"?
A. This screening test item must be coded using the appropriate response which reflects the presence or absence of a limitation.
Q. How do you code a resident who has arthritis in both hands but is able to dress self?
A. There is not enough information provided to answer the question. A diagnosis of arthritis does not necessarily have an impact on function. To determine the code, you must consider two parameters: completion of the task (i.e., not interfering with daily functions) and coordination of movements. You have already determined that the resident is functionally able to complete the task of self-dressing, which would rule out code "2". If the resident has full ROM in both hands, use code "0". Next determine coordination of movements. Select code "0" if the resident's movements were smooth and coordinated; code "1" if the resident's movements were slow and uncoordinated. Refer to the coding instructions in the User's Manual, page 3-98.
Q. Resident has bilateral problems with different coding for each side?
A. For column A code "2 - Limitation on both sides of the body". The assessor may indicate on the document which side (R or L) is involved and the code for each. For Column B, coding is dependent on whether there is partial or full loss of voluntary movement. [User's Manual, pages 3-95 through 3-98]
Q. How do I differentiate on which side the resident has a range of motion problem?
A. It's not necessary to differentiate when coding a "1". However, you may note right or left side on the form.
Q. A resident cannot or will not follow directions to perform each movement in the range of motion test (perhaps due to impaired cognition). Do we passively move him/her through the functional movements for each test? How should G4 be coded? A. This is a good question because many residents in nursing facilities are cognitively impaired. These items are coded based on the resident's ability to perform range of motion and voluntary movement. For G4, column A, a resident who is unable to follow your verbal instructions or a demonstration of movements can be actively assisted in range of motion exercises to assess for limitations. Move the resident's joints through slow, active assisted ROM by providing support and direction with each activity. In this section, you can also use observations by the staff of what the resident can do. [User's Manual, page 3-96]
Q. When a resident cannot/does not have voluntary ROM due to impaired cognition, yet at other times strikes out or makes movements considered ROM, how is this coded?
A. You can use staff observations of the ROM activity to determine whether a resident can actually perform the activity, regardless of whether the movement was "on command", provided the movement fits the criteria on page 3-96 of the User's Manual and that it occurred during the assessment period of observation.
Q. When dealing with an immobile or very confused individual who cannot don/doff a shirt or perform other tests as described in the User's Manual, what specific functional ranges are used for AAROM (e.g., at shoulder 90 flexior/abduction, ankle 0 dorsiflexion)? Guidelines for degrees would be very helpful!
A. Remember this test is a screening item used to determine the need for therapy evaluation.
Q. How would you code G4 for a comatose resident?
A. The appropriate code for G4, column A would depend on the results of the range elicited in passively moving the extremities [User's Manual, page 3-96]. Item G4, column B would be coded "2". [User's Manual, page 3-98]
G5. Modes of Locomotion
Q. Would you code a resident who uses a motorized cart as "b. Wheeled self" or "e. None of the above"?
A. This resident could be coded as "b. Wheeled self" or "d. Wheelchair primary mode of locomotion". [User's Manual, 3-99]
G7. Task Segmentation
Q. If the resident is compromised due to a respiratory ailment and we break down his ADL task to allow specific time lapse between each task, is this considered task segmentation?
A. Yes. [User's Manual, 3-100]
G9. Change in ADL Function
Q. In the last 90 days the resident's status fluctuated (i.e., decrease in ADL, increase in ADL, then decrease in ADL status). What do you do?
A. The 90 days refers to a fixed point in time, i.e. 90 days ago (or since the last assessment if less than 90 days). The comparison is between the current assessment and either of the above, not for periods in between. [User's Manual, 3-104]
Q. What is the difference between "scheduled toileting plan" and "bladder retraining program" (Item H3)?
A. Refer to page 3-108 in the User's Manual.
Q. If a resident goes from use of foley catheter (score of "0") to removal of foley catheter with total incontinence (score of "4"), is change in urinary continence considered deterioration on Item H4?
A. Yes. The issue is performance. [User's Manual , 3-110]
Q. Regarding Item H4, Change in Urinary Continence: If a resident's condition has changed from dribbling urine without an indwelling catheter to dry with a catheter, would this be coded "1, Improved"?
A. Yes. According to the User's Manual on page 3-110, "Although one could perceive that [the resident] has 'deteriorated' because he now has a catheter for bladder control, remember that the MDS definition for bladder continence states 'Control of bladder function with appliances (e.g., foley) or continence programs, if employed.'" The key issue in coding MDS items is "objective performance". In this case, the resident is continent and therefore coded as "improved", even though the catheter is the basis for the change in status.
Q. In Item I2, no time frame is given for pneumonia as it is for UTI. Why?
A. All items refer to the past seven days unless specified differently.
Q. If a resident is on medication for an active diagnosis but is stable, would diagnosis be checked?
A. Yes, if the criteria for inclusion as described in the intent of this item are met. [User's Manual, pages 3-110, 3-111, and 3-113]
Q. Pneumonia and respiratory infections are both mentioned in Item I2. How do we work through this to code correctly?
A. Review the definitions on page 3-116 of the User's Manual. A key point according to the manual is that a "respiratory infection is any upper or lower (e.g., bronchitis) respiratory infection other than pneumonia." If the resident has only pneumonia, check only Item I2e, rather than both I2e and I2f.
Q. Regarding HIV confidentiality: Does staff need authorization to complete I2d?
A. HCFA and New York State treat the item for HIV infection the same as for other clinical diagnoses. All such clinical information is considered confidential and protected as a part of the resident's clinical record.
Q. Does an HIV-affected resident need to be informed and/or give consent to MDS transmittal of information related to HIV information?
A. No.
Q. Where do we identify a nutritional diagnosis (on MDS+, was in Section K; not on MDS 2.0)?
A. If the resident has a diagnosed nutritional deficiency which meets the criteria for inclusion in Section I, the appropriate ICD 9 code may be entered in I3.
Q. Item J1a asks about weight gain or loss of three pounds or more within a seven-day period. Does this mean that, as residents come up for assessment, they need to be weighed and then weighed again seven days later?
A. No, unless weighing is indicated based on the resident's clinical condition.
Q. Item J1d (Insufficient fluid; did not consume all/almost all liquids provided during last 3 days): If you look at fluid intake vs. guidelines for calculating fluid needs, more than 50% of the residents at the facilities where I work don't meet needs. Fluids are offered with meds and meals as well as between meals, but many residents do not consume "all/almost all fluids". It is quite difficult to obtain an accurate accounting of all fluids. Any suggestions here?
A. As with all items, this item should be answered as it is asked. It is the responsibility of nursing home staff to identify residents who may be at risk for dehydration.
Q. How do I assess pain in a non-verbal resident (Items K2 and K3)?
A. Refer to pages 3-121 to 3-122 in User's Manual.
Q. What is the definition of a fall (Item K4) for RAI purposes?
A. "Fall", according to Webster's Second College Edition Dictionary, is defined as "to come down suddenly from a standing or sitting position, to tumble; to topple; to become prostrate." This definition is to be used for MDS coding purposes.
Q. Who can decide end stage disease (Item K5)? Must a physician make this determination?
A. Refer to page 3-126 in User's Manual.
Q. If resident has a G-tube due to dysphagia, should K1b (Swallowing Problems) be checked?
A. Yes. [User's Manual, page 3-127]
Q. What information is entered on the MDS if staff are unable to obtain a resident's weight (Item K2)?
A. There may be circumstances under which a resident cannot be weighed (e.g., extreme pain or immobility, risk of pathological fractures, resident refusal, hospice care). If, as a matter of professional judgment, a resident should not be weighed, use the standard "no information" code, which is either a "circled dash" or an "NA". The reason the resident was not weighed should be documented in the resident's clinical record as well.
Q. In Section K, is documentation required for 7.5% significant weight change in 90 days?
A. Weight change is recorded in K3a only when there is a minimum weight loss or gain of 5% or more of total body mass over 30 days or a 10% or greater loss or gain over 180 days. In this example, scoring of K3a would depend on how much of the 7.5% weight change occurred over the last 30 days. Documentation of the identification and evaluation of weight change is good clinical practice. The significance of the weight change for that resident should be reflected within that documentation.
Q. For Section K, are there any regulations or guidelines related to desirable weight gain or loss time frames? How much weight loss in what period of time is considered too fast?
A. There are no specific regulations that address the desirable weight and time frames for weight gain or weight loss. The amount of weight gain or loss reflects individual differences. However, there is some general information in the interpretive guidelines and in the Nutritional RAP that may provide guidance in this area. Guidelines related to acceptable parameters of weight gain and loss are addressed in the OBRA regulations at 42 CFR 483.25, nutrition (F325 and F326), and 483.20(b)2(v), resident assessment nutritional status and requirements (F 272). These correspond to the MDS Section K, Oral/Nutritional Status.
The parameters for weight loss identified in the guidelines referenced above are:
1 month, 5% = significant; > 5% = severe
3 months, 7.5% = significant; > 7.5% = severe
6 months, 10% = significant;> 10% = severe
The measurement of weight is a guide in determining nutritional status. Therefore, the evaluation of the significance of weight gain or loss over a specific time frame is a crucial part of the assessment process. An adequate assessment should result in a "comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's needs."
Q. If a resident meets the criteria for weight gain or loss of 5% in 30 days or 10% in 180 days but is on a planned weight change program, do you answer "yes" to Item K3 and trigger on RAPs?
A. Yes. K3a should be coded "1, Yes" and K5h should be checked as well.
Q. In Section K, what is checked for a resident who is on tube feeding but receives a therapeutic feeding (e.g., pudding) only at usual mealtime?
A. Item K5b would be checked. Item K5e would be checked if the pudding was ordered for therapeutic, not socialization, purposes.
Q. Supplements during meals: Is therapeutic diet (K5e) only checked when there is a physician's order for it?
A. Yes. [User's Manual, 3-130].
Q. For calculating the average fluid intake per day for tube feeders (K6), do we need to calculate specific amount of water given with medication via tube plus tube feeding formula?
A. Yes, the average is based on all fluid ingested by the resident.
Q. Are we figuring average fluid intake (Parenteral or Enteral Intake, K6b) using total fluids or available fluids (as dietitians commonly use)?
A. This item refers to the actual amount of fluid the resident received. [User's Manual, 3-133]
Q. Are all ulcers "staged" regardless of cause, i.e., pressure vs. stasis (venous)?
A. Yes. Refer to User's Manual, pages 3-134 and 3-135.
Q. Current literature on staging pressure ulcers suggests that stage 4 ulcers which are healing cannot be characterized as stage 3, stage 2, and stage 1, as they are healing. The alternate approach is to identify the ulcer as a healing stage 4 ulcer. Consultants and providers are very upset that they have spent the past year training personnel how to stage ulcers in this manner, but the MDS encourages them to use a reverse staging system. Can we have resolution? For example, is a healing stage 3 pressure ulcer coded as a "3" or "2"?
A. Code it as a stage 3. For the MDS Version 2.0, code the ulcer in terms of what you see (i.e., visible tissue). That is, the MDS should be coded the way it was in the original version. Currently, there is no uniform nomenclature or scoring system approved for coding a healing pressure ulcer. In the clinical record, describe the appearance of the healing ulcer (i.e., presence of granulation tissue, size, depth, color, and so forth).
Q. How do I stage decubitus ulcers when healing?
A. Stage the ulcer using definition on page 3-134 of User's Manual (i.e., as the ulcer presents).
Q. Are ankle problems to be included in Item M6, Foot Problems and Care?
A. No. The ankle is the joint between the ankle and foot and is not included here. If you are dressing the foot as well as the ankle, code the foot issues in M6 and code the ankle issues in M5 (for instance, by checking g or h).
Q. Regarding Item M6d (Nails/calluses trimmed during the last 90 days): The guideline in the User's Manual on page 3-140 includes trimming by a nurse or any health professional including a podiatrist. Is a CNA considered a "health professional" for the purpose of coding this item?
A. No. The item is intended to capture licensed professional time.
Q. Item N2 (Average Time Involved in Activities) is not clear. Does this mean while awake or involved in activities?
A. Item N2 refers to the amount of "free time" residents have while awake and not receiving nursing care or treatments or not engaged in ADL activities. This is time they, therefore, could be involved in activity pursuits and therapeutic recreation of their choice. This item has a seven-day observation period, which should give an accurate indication of a resident's activity involvement pattern. [User's Manual, 3-141]
Q. Is time spent eating to be included in the calculation of time available for activities (N2)? In other words, is dining considered an activity?
A. Although dining is a social experience for some residents and, at times, meals may be planned around certain events or occasions, eating is not to be counted as an activity. [User's Manual, 3-141]
Q. Is time spent involved in independent, unstructured leisure activity (for example, watching favorite soap operas, talking on the phone, knitting) to be included in "average time involved in activities" (N2)?
A. Yes. Include time spent in pursuing independent activities (e.g., watering plants, reading, letter-writing); social contacts (e.g., visits, phone calls) with family, other residents, staff, and volunteers; recreational pursuits in a group, one-on-one or on an individual basis; and involvement in therapeutic recreation. Refer to the User's Manual, page 3-141. Keep in mind that the definition of "activity pursuits" refers to any activity other than ADLs that a resident pursues in order to enhance a sense of well-being. Efforts should be made to provide activities suited to the resident's preferences and capabilities.
Q. Is it accurate to say that cognitively impaired residents would likely be coded in Item N2 as having little or no involvement (based on available time), since they are lacking the ability to consciously "pursue" their interests?
A. No. Many cognitively impaired persons continue to "pursue" their interests and also develop new interests. Activities must be tailored to their cognitive abilities. Record the amount of time the person spends in structured and non-structured activities. Refer to pages 3-140 to 3-142 of the User's Manual, which includes a broad definition of activity pursuits.
Q. Define activity "pursuits" vs "programs", and how the assessment guidelines distinguish between what the resident prefers and what the facility offers.
A. N4 refers to resident activity preferences (adapted to the resident's current abilities). N5 determines if the resident is interested in activities that are either not offered or are offered but not available to the resident. [User's Manual, 3-142 and 3-143]
Q. Where would you record a preference for activities such as trivia games, intellectual groups, or party-type activities?
A. If the activity is predominantly a social-type activity, record it under N4k. If the activity is more "game-like" in nature, then record it under N4a. The MDS does not provide a separate item to document resident's preference for every possible type of activity. Coding decision should be based upon the predominant overall nature of the activity. [User's Manual, 3-142]
Q. Why is there no question in Activity Pursuit Patterns (N4) for pet therapy?
A. Not every item could be captured in the MDS 2.0. This is a good item to document in the resident's record.
Q. Is Sustacal or any nutritional supplement considered a medication as it relates to Section O?
A. Section O is designed to capture data concerning the use of over-the-counter and prescription medications. The User's Manual on page 3-145 expands the definition of medications to include topical preparations, ointments, creams used in wound care (e.g., Elase), eye drops, vitamins, and suppositories. Vitamins should be counted (as noted below). Sustacal is not counted as a medication for coding in Section O even though the pharmacy sometimes supplies such items. Sustacal could be recorded in Item K5, provided it fits the definitions.
Q. In Item O1 (Number of Medications) are B12 injections that are given once per month, but outside of the assessment period, included (as are the long acting antipsychotics illustrated in the User's Manual)?
A. Yes. If the resident received an injection of Vitamin B12 prior to the observation period, code in Item O1. Vitamin B12 maintains a blood level, as do long acting antipsychotics.
Q. If a resident receives more than one type of insulin, is each type recorded in Item O1?
A. Yes. For example, Lente, Humulin, and Regular are different types of insulin and are considered different medications.
Q. Does Item O3 (Injections) include B12 injections given once per month but outside of the observation period?
A. No. In O3, code only the injections administered during the observation period.
Q. Is Aracet used to treat Alzheimer?s Disease coded in O4a, b, or c?
A. No, this medication is not coded as a psychotropic drug.
P1. Special Treatments, Procedures, and Programs
Q. For those residents admitted in a comfort care program with a prognosis of six month or less, may they be checked off in Item P1a as Hospice Care?
A. Yes. [User's Manual, page 3-150]
Q. Will mental health units now be classified as Alzheimer's/dementia special care units?
A. Yes, if they meet criteria. [User's Manual, 3-150]
Q. When looking at time for PT, OT, or speech, do we consider direct resident contact time only? For example, if you set up a resident for a treatment, is the entire time of the treatment counted or only the start/stop time required by the professional?
A. The MDS 2.0 measures the resident's characteristics and services received. The amounts of time reported in Item P1b must be the "resident's time in treatment", not the time and effort of the staff to produce and document treatment. The treatment time starts when the resident begins the first treatment activity or task and ends when he/she finishes with the last apparatus and the treatment is ended. Set-up time is also included. In some cases, the resident will be able to perform part of the treatment tasks with supervision, once set up appropriately. Time supervising the resident is a part of total treatment time.
For example, as the last treatment task of the day, a resident uses an exercise bicycle for 10 minutes. It may take the therapist 2 minutes to set the resident up on the apparatus. The therapist, or assistant under the supervision of a PT, may then leave the resident to help another resident in the same exercise room. However, the therapist still has eye contact with the resident and is providing supervision, verbal encouragement, and direction to the resident on the bicycle. In this case, if the therapist took 2 minutes to set up the resident with the cycling apparatus, the resident was supervised during two 5-minute cycling periods, there was one 2-minute rest between the exercise periods, and the resident took 1 minute to get out of the apparatus, the total cycling activity is 15 minutes. In this example, if the resident did three additional treatment activities totaling 45 minutes before beginning to cycle, the total time reported on the MDS is 60 minutes. The key is that the resident was receiving treatment the entire time and had the physical presence of a therapist, supervising the entire treatment process.
Q. If OT is using/supervising a horticulturist, can these minutes be counted as part of therapy under P1b?
A. No. Therapies such as art, music, dance, or horticultural should be coded under T1a, providing the qualifiers are met.
Q. If a resident attended physical therapy five days (Monday through Friday) in the last seven days for 30 minutes a day and attended physical therapy in a group two days (Thursday and Friday) in that week for 60 minutes each session, how do you code Item P1b?
A. Column (A) days = 5 days; Column (B) minutes = 270 minutes. [User's Manual, 3-150]
Q. Where do we count therapy minutes for maintenance performed by a PTA?
A. In Item Pb1, count minutes for physical therapy under Column B. [User's Manual, 3-151]
Q. In User's Manual, page 3-152, example has 70 minutes entered for respiratory therapy. Is this an error since it was less than 15 minutes per day?
A. No, the example is correct. P1b, column B, refers to the total minutes for the past 7 days.
Q. Can respiratory therapy be done by LPN rather than an RN? The manual says a "trained nurse".
A. In New York State, only an RT, PT, or RN may provide respiratory treatments.
Q. Are Ventolin inhaler treatments given multiple times daily considered respiratory therapy?
A. No, Ventolin dispensed in a metered dose is not considered to be respiratory therapy. [User's Manual, 3-151]
Q. Does Bi-Pap therapy count under respiratory therapy if RN is doing it and/or applying appliance?
A. Yes, Bi-Pap therapy used to treat sleep apnea may be counted if the 15 minute per day criteria is met.
Q. Item P1, Psychological Therapies: Does a certified social worker (with Master's and certification) count as licensed mental health professional?
A. Yes. [User's Manual, 3-151]
Q. What are the qualifications for psychiatric social worker or a psychiatric nurse?
A. A psychiatric social worker must be an MSW/CSW. Psychiatric nurses have a Master's degree and/or certification from the American Nurses Association as a psychiatric nurse specialist.
Q. If one physical therapist has a group of five residents in an activity, does each resident get the full value of the therapist's time (Item P1b), or is that time shared among members of the group?
A. Generally, in a group larger than four residents, the residents are receiving supportive services, not treatments, unless there are at least two staff persons with the group. For the most part, Item P1b assumes individualized treatment and the category does not include services received as part of a group of more than four residents per supervising helper (as stated in the Nursing Rehabilitation section on page 3-154 of the User's Manual). If, however, the group has four or fewer residents per supervising therapist (or assistant), give each resident the full time value spent in the therapy session. For example, if a therapist worked with three residents for 45 minutes on training to return to the community, each resident received 45 minutes of therapy. Remember to code for the resident's time, not the therapist's time.
Also the service must meet all of the following criteria to be coded in the therapy section:
* In New York State the service must be ordered by a physician or nurse practitioner.
* The therapy intervention must be based on a qualified therapist's evaluation and plan of care as documented in the resident's record.
* An appropriate licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services.
Q. In Section P, Special Treatments, what is minimum number of residents for a group therapy session run by a social worker? Would social worker be required to do individualized treatment plan for each group member?
A. More than one resident could be considered a group. Each group member must have an individualized treatment plan. See general requirements for therapy in User's Manual, page 3-150.
P3. Nursing Rehabilitation
Q. Do the 15 minutes for nursing rehab have to be straight time or can the 15 minutes be over a 24-hour period?
A. The 15 minutes do not have to occur all at once. There must be a total of 15 minutes over a 24-hour period. Refer to coding in User's Manual, page 3-155.
Q. How do you calculate the minutes for nursing rehab? Is rounding up acceptable? If so, what is the cut off? (For instance, we are teaching standing skills and the resident can only stand for 5 minutes once daily. Time is being spent and hopefully a positive outcome is taking place and the resident will increase in time.) Under the criteria set, you would have to code "0".
A. Rounding up is not acceptable. In the scenario described, the coding would be "0". Refer to coding in the User's Manual, page 3-155.
Q. What if a resident in a nursing rehab program is sick and misses a day. Can you make up the days with extra minutes the next day?
A. For MDS coding purposes count only the sessions the resident attended during the observation period.
Q. What are the documentation requirements for nursing rehabilitation (P3) for the time frame of 15 minutes?
A. Facilities should develop and implement their own policies and forms with regard to documentation.
Q. Can an LPN coordinate nursing rehab program if RN co-signs all related documentation?
A. Rehab nursing activities are carried out or supervised by licensed nursing staff. However, it is not within the scope of practice of an LPN to plan or evaluate resident care. Evidence of periodic evaluation by a registered nurse must be present in the clinical record.
Q. Can we capture maintenance physical therapy minutes under restorative nursing (P3) if supervised by a physical therapist but performed by CNAs?
A. No. To be considered as restorative nursing (P3) it must be planned and supervised by nursing. [User's Manual, pages 3-153 through 3-155]
Q. How long do the group programs last under restorative nursing?
A. In order to capture nursing rehab in P3, the rehabilitative or restorative techniques must be practiced at least 15 minutes over a 24-hour period. There is no requirement as to how long such programs are in place. They need to last as long as necessary as dictated by resident needs and abilities. [User's Manual, 3-155]
Q. Regarding Items P3a & b: The guidelines on User's Manual, page 3-154 include a definition of active range of motion but not of passive range of motion. What is the definition of passive range of motion to be used in completing these MDS items?
A. Passive range of motion - The care giver moves the body part around a fixed point or joint through the resident's available range of motion. The resident provides no assistance. Code under P3a.
Q. How specifically do you have to document for range of motion?
A. Range of motion instructions must be specific enough for staff to give and document care.
Q. If the activities department is doing an exercise/ROM program, can it be counted for the range of motion for Rehab Nursing?
A. No. An exercise/ROM program done by activities doesn't meet criteria described in User's Manual, page 3-154 (that is, carried out or supervised by members of the nursing staff; measurable objectives and interventions documented in the care plan and clinical record, etc.).
Q. Can nursing initiate range of motion program without consultation with PT or OT?
A. Yes. The intent of nursing rehab is to determine the extent to which the resident receives nursing rehabilitation or restorative services from other than specialized therapy staff (e.g., occupational therapist, physical therapist, etc.). [User's Manual, 3-153]
Q. P3c, splinting: For scheduled applying and removing, do you count the total time on or the total time to apply and remove?
A. You would count time for application, removal, assessment, repositioning and resident/family education, not the total time the appliance was on. These sessions are planned, scheduled, and documented in the clinical record. Note that splint or brace assistance can be of 2 types: 1) staff provides verbal and physical guidance and direction that teaches the resident how to apply, manipulate, and care for a brace or splint, or 2) staff has a scheduled program of applying and removing a splint or brace, assessing the resident's skin and circulation under the device, and repositioning the limb in correct alignment. [User's Manual, page 3-154]
Q. Regarding transfer (P3e): On rehabilitation and restorative care, is it only self-performance we look at?
A. Activities which increase self-performance will also decrease amount of assistance needed. The focus, however, is self-performance.
Q. Dressing or grooming (P3g): Can you combine these two for the 15-minute qualifier, or do you have to spend 15 minutes on dressing alone or grooming alone?
A. No, each activity (e.g., dressing, washing) must be counted separately.
Q. Nursing rehab must be planned by and show evidence of periodic evaluation by an RN. What if it is a feeding training program planned by OT and supervised by OT? Wouldn't it be evaluated by OT, not RN, or do they co-develop and evaluate?
A. A feeding training planned and supervised by OT would not be nursing rehab. Nursing rehab programs should be collaborative and consultative with any disciplines as required for implementation. In order to be captured as nursing rehab, the program must meet all criteria (see User's Manual, pages 3-153 to 3-155) which includes being planned and carried out under nursing supervision with evaluation by an RN.
Q. Our administrator checked with the state on feeding residents. She was directed that feeding residents could only be done by OT, ST, CNA, LPN, or RN. How can a volunteer feed?
A. According to State of New York - Department of Health Memorandum, Health Facilities Series: NH-26, HRF-25 82-72 dated November 24, 1982, volunteers are allowed to assist with feeding patients in voluntary and public nursing homes. However, the Department is mindful that the New York State Labor Law and the Federal Fair Labor Standards Act continue in effect where proprietary facilities are concerned. Accordingly, the Department continues prohibition of volunteers assisting with feeding patients in proprietary facilities.
P4. Devices and Restraints
Q. Is a merry walker used as means for independent ambulation considered a restraint? We were informed that a merry walker was not considered a restraint on a particular resident. Is this a judgment call, or is a merry walker always considered a restraint?
A. Merry walkers can be very helpful mobility devices for some residents. However, for others (e.g., for residents who wander), merry walkers may be a restraint. Staff should code merry walkers in G5a (walker) as well as P4e (chair that prevents rising). Staff would then assess its necessity during a review of the Restraint RAP. This logic is similar to that used for bed rails in terms of whether they are considered as enablers or restraints.
Q. Is a lounge chair which is used for comfort for a non-ambulatory resident with poor trunk balance considered "chair that prevents rising" [P4e]?
A. Yes. Use objective observation when coding this question. [User's Manual, 3-158]
Q. We have many residents in our facility for whom our MDS Coordinator states we need to count recliners (e.g., home comfort recliners) as restraints when the resident is a two-person assist.
A. For coding purposes recliners are coded as a "chair that prevents rising" (P4e). [User's Manual, 3-158]
Q. Do full rails and geri-chair have to be coded as a restraint/device if the resident's body is its own restraint (e.g., quadriplegic, coma)?
A. Yes, code for the objective presence of the device. [User's Manual, 3-158]
Q. Item G6b assesses whether "bed rails are used for bed mobility or transfer". Item P4a (Devices and Restraints) documents whether full bed rails are used. Will this identify enablers as restraints on the HCFA 672?
A. Item P4 identifies whether full or partial side rails are used but does not make a judgment regarding whether they are used as a restraint. When the side rails are used to assist in mobility and Item G6b is also checked, for the purpose of completing the HCFA 672 form, G6b minus P4a and b identifies restraints.
Q. Is a side rail always checked on the MDS, even if it is not a restraint because the resident is able to get out of bed himself?
A. Yes. Code for the objective presence of the rail. [User's Manual, page 3-158]
P5 - P7. Hospital Stays, Emergency Room Visits, Physician Visits
Q. How do we code a resident who is in the hospital for less than 24 hours for a procedure (e.g., short-stay surgery/same-day surgery), but is not admitted to the hospital, is not discharged from nursing home, and is not seen in the emergency room?
A. It is not coded as either a Hospital Stay (P5) or Emergency Room Visit (P6). This information would be documented in the medical record as per facility policy.
Q. A local hospital has "observation" beds where they may hold a resident up to 48 hours but not admit them. Is this considered an emergency room visit (P6) or admission D/T overnight (P5)?
A. If it is hospital policy to observe a resident in a dedicated area prior to admission and the resident has an overnight stay, this is considered a hospital admission (P5) for MDS coding purposes.
Q. Regarding physicians visits (P7): Does this include consulting physicians or attending only?
A. Yes, include consulting physicians. [User's Manual, 3-161]
Q. Does out-patient surgery at a hospital count a physician visit (P7)?
A. No. A physician visit does not take place in a hospital, only in an physician's office or the nursing facility. [User's Manual, page 3-159]
Q. How do I fill out Section Q (Discharge Potential and Overall Status) for the resident who prefers to return to the community but is homeless?
A. In Item Q1 code as follows: a) Resident expresses/indicates preference to return to the community = "1, yes".
b) Resident has a support person who is positive towards discharge = "0, no".
c) Stay projected to be of a short duration = "3, uncertain".
This situation warrants further consultation with primary staff and social service staff. [User's Manual, page 3-162]
Q. If a resident has an acute process going on during the seven-day assessment period but will return to the same status with time, should Item Q2 be coded "no change"?
A. No. Refer to User's Manual, page 3-164.
Q. Do business office staff members have to sign Section R if completing Item A7?
A. Yes. [User's Manual, page 3-167]
Q. Completion of MDS is broken into disciplines. One section might have 3 different assessors completing different questions (e.g., Section B, Items 1 and 5 by nursing; Items 2, 3, 4, 6 by social service). We used to prepare MDS+ forms with stamps. Now there is no room on the MDS 2.0 form. It is time consuming for all disciplines to write in assigned sections and items and also there is no room. Is it permissible to have facility policy stating what discipline is responsible for what sections and items and then sign Section R and note in sections area "per policy"?
A. No. Individuals must sign name, indicate title and sections completed. They are not required to sign their discipline next to their name (example: dietary, nursing) to account for the section completed. A stamp can still be utilized. [User's Manual, 3-167]
Q. If there are more then six assessors completing the MDS, is there a sheet available for the extra signatures?
A. Other individuals completing MDS should sign and date on available space (under "other signatures"). [User's Manual, pages 2-18 and 3-167]
Q. When does Section S get filled out? Frequency?
A. Section S is completed with every assessment.
Q. Does recreation therapy require a physician's order?
A. Yes. [User's Manual, page 3-168]
Q. How do you code number of pills (U4) when the order is different from the pills supplied?
A. "Amount administered" is defined as the "number of tablets...per dose that is administered to a resident". [User's Manual, page 3-176]
Q. The new manual does not include NDC codes as the old manual did. Is there an easy-to-use source other than pulling out the PDR each time?
A. If your pharmacist is involved in completing this section, he/she would be able to provide this information. [User's Manual, 3-184]
Q. In the example in the User's Manual on page 4-32, the Visual Function RAP is not checked as triggered, but in the example on page 4-27, Item D1 = "1". Should the Visual Function RAP have been checked in this example?
A. Yes. The Visual Function RAP triggered in this example and should have been checked on the example RAP Summary Form on page 4-32.
Q. Why is the Visual Function RAP not triggered when D1 = "4"?
A. Potential for visual improvement is not indicated if D1 = "4".
Q. Please explain the difference between ADL Rehabilitation triggers A and B.
A. Refer to the ADL RAP information in the User's Manual, RAPS Activities of Daily Living under Triggers. "The two MDS trigger categories (A and B) suggest the types of residents for whom special care interventions may be most important. Such residents may have either the need and potential to improve (Rehabilitation) or the need for services to prevent decline (Maintenance)." If a resident triggers the ADL RAP, he/she will trigger ADL category A, B, or both, as determined by the responses to MDS items linked with each category.
If category A is triggered, a rehabilitation/restorative plan of care is suggested. If category B is triggered, a plan of care designed to maintain function/avoid complications is suggested.
For residents who trigger both ADL categories A and B, category B takes precedence in the RAP review. A resident who codes "no ability to make decisions" (B4 = "3") is not a rehabilitation candidate, but rather an individual whose care plan would be designed to maintain function.
Q. Why is the Activities B RAP triggered if just N1a ("morning") is checked?
A. Note that N1a alone does not trigger the RAP. Rather, it must be present in combination with N2 = "0". Analysis of MDS data sets demonstrated that these two items ("awake all or most of morning" and "more than 2/3 time involved in activities") were highly predictive of possible over-stimulation of residents. This suggests a need for additional assessment and possible revision of the activity care plan. For example, the resident may be so involved in activities that he/she becomes too tired to eat. On the other hand, a high degree of involvement in activities may be used in a therapeutic manner by a resident who is depressed.
Q. If a resident is up in the morning and afternoon or any configuration involving morning, does that also trigger?
A. When N2 is coded as "0, more than 2/3 of time" and "Morning" is checked for N1, Activities B RAP is triggered calling for a review of the care plan. If N2 is coded either "2, less than 2/3 of the time" or "3, none" for time involved in activities, Activities A RAP is triggered suggesting a revision of the activity plan. See Resident Assessment Protocol (RAP) for Activities.
Q. Why doesn't unsteady gait trigger falls?
A. Revised triggers on the MDS 2.0 have been determined statistically by their predictive power. Triggers were studied to determine which triggers contributed most significantly to the identification of problems warranting care plans. Trigger items with low predictive validity were eliminated.
Q. In Section O, Medications: Why doesn't a hypnotic drug trigger the Psychotropic Drug Use RAP?
A. Hypnotic drug use does not add any discriminating ability in terms of identifying residents who warrant additional assessment.
Q. If a resident receives an antipsychotic and an antidepressant, would this then trigger the RAP?
A. To be triggered, the resident must first use a psychotropic drug and also have one or more of the items in the Psychotropic Drug Use column indicated by a solid black circle. [User's Manual, page 4-7]
Q. What information on the Resident Assessment Protocol Summary will be submitted?
A. Section V, Item A, columns (a) and (b); Items B1, 2, 3, and 4.
Q. Please review the B2 and B4 dates on the Resident Assessment Protocol Summary?
A. For all full assessments, the RAP assessment process must be completed within 14 days and the care plan completed seven days after MDS and RAPs are completed. [User's Manual, page 2-28 and 2-29]
Q. Can the same person sign B1 and B3 on the RAP Summary sheet?
A. Yes, provided that person actually completed both functions. It is not a requirement that the same person complete both. Keep in mind that B1 must be an RN. [User's Manual, page 4-18]
Q. Can the RAP note be used for the quarterly summary?
A. The RAPs are not required for the quarterly assessments. [User's Manual, 3-2]
Q. Why can't the previous care plan be used for RAP documentation?
A. The ICP is the result of the assessment process and is not the assessment tool. [User's Manual, 4-11]
Q. If your facility has printed guidelines, can this be your RAP note if the information is noted here and dated?
A. Yes, written documentation of the RAP findings and decision-making process may appear anywhere in the resident's record. All four factors described on page 4-5 of the User's Manual should be present on RAP assessment documentation. Also refer to User's Manual, page 4-11.
Q. The examples of documentation when triggering a RAP do not specifically state ?Therefore resident triggers RAPs for x, y and z.? Is this necessary?
A. It is important that information from the assessment that leads to the care planning decision be clearly documented. Refer to User's Manual, pages 4-10 to 4-11.
Q. Do you need to keep attendance for those at care planning (since there is only one signature on the RAP Summary)?
A. There is no HCFA or state requirement, but it is good facility practice.
Q. With the time changes in assessment do we still have until the 21st day to meet as a care plan team?
A. Facilities have seven days after the completion of the RAI assessment to develop or revise the resident's care plan. The RN coordinator should sign and date the RAP Summary Form after all triggered RAPs have been reviewed to certify completion of the comprehensive assessment (Section V, Items B1 and 2). Facilities should use this date to determine the date by which the care plan must be completed.
Q. Please clarify the differences between Activities RAPs A and B and how evaluation of the care plans would differ.
A. The Activities RAPs A and B point to very different treatment strategies. Trigger A identifies the need to evaluate expanded care/activity involvement when current involvement levels are low or new activity options are desired by the resident. Trigger B identifies the need to evaluate how to manage and possibly reduce activity patterns when involvement in activities is high and consistent throughout all waking hours of the day.
Q. Do we need to care plan for all weight losses? What if it is expected?
A. The care plan must consistently reflect the resident's current status.
Q. In the example on page 4-26 in the User's Manual, is the date at Item A3a correct?
A. No. A3a in this example should be dated 09-01-1995. This was previously acknowledged by HCFA and sent out as a correction.
Q. Are there any other "errors" in the User's Manual? Is there written documentation from federal government that changes are made from the "official" manual?
A. There are a few "clarifications" in the User's Manual specific to New York State facilities:
* Page 2-6, last paragraph - "Day of Admission" is counted as day "1".
* Page 3-151, paragraph 4, Respiratory Therapy - trained nurse in New York State must be RN.
* Page 3-154, paragraph 2 - Periodic evaluation by registered nurse, not licensed nurse.
Q. How is an October 1995 version of a User's Manual appropriate when Section S for NYS had not been developed? Is this truly the "HCFA" Manual we are to follow or is it merely an introduction tool?
A. The October 1995 manual must be utilized. Changes specific to NYS have been identified (see above). Section S, the state-specific section, comes with its own instructions. [See User's Manual, 3-167]
Q. What are the "real" consequences of miscalculating annual or quarterly reviews (e.g., late entry)?
A. The intent of the RAI is accuracy and timeliness. The facility should look at "miscalculations" and/or "late entries" as internal quality assurance issues.
Q. When will the MDS 2.0 be used for reimbursement?
A. After PRIs are phased out. At this time, no final date has been established.
Q. What is happening with data collected from 1991? Is the data helpful for what we are actually seeing currently in long-term care?
A. The data has been used for the Medicare Demonstration Project. Additionally, facilities have used the information for internal quality assurance studies.
Q. Are the MDS 2.0 questions giving us more reliable data for our quality indicators?
A. Yes. The Wisconsin Quality Indicators were taken into account when designing the MDS 2.0.
Q. Some surveyors are mandating that only narrative documentation can be used for RAP review documentation and are giving deficiencies if any other format is used. Please comment.
A. The guidelines found in the SOM Transmittal #272 address the content, but not the format, of RAP review documentation. Indeed, in Chapter 4 of the User's Manual, it is clear from both the text and documentation examples that facilities have a great deal of flexibility in how this documentation is done. Citing facilities for failing to use a narrative format cannot be supported under the federal requirements. Rather, HCFA provides guidance on key documentation in Chapter 4 of the User's Manual. If it is not clear that a facility's documentation provides this information, surveyors should ask facility staff to provide such evidence.
Q. Regarding RAP documentation: How much documentation is enough? For example, if a resident is incontinent and most documentation is present but there is no note regarding family involvement in the care plan, should the survey team cite this?
A. Not necessarily. Refer to the examples of resident assessment documentation in the User's Manual on pages 4-11. The main issue is whether facility staff have documented key findings regarding the resident's status and associated implications for care. If the family is particularly involved in the resident's care or concerned about the incontinence problem, then it may be appropriate for some reference to the family to appear in facility documentation. However, surveyors should not expect to see references to family involvement for each triggered RAP or care plan problem.
Q. Now that the enforcement regulation refers to each resident, if assessment of RAP documentation information is inadequate, is it appropriate to cite 272 even if there is only an occurrence for one individual?
A. It's difficult to provide precise guidance on what constitutes an inadequate assessment. Generally speaking, this decision should be based on whether the resident received appropriate care to meet his/her medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. As stated in the regulations at CFR 483.20, the comprehensive assessment provides the foundation for the development of a care plan that meets these needs. If the facility did not accurately identify and care plan for the resident's needs because of an inadequate assessment, this could be cited as a deficiency.
Q. Regarding the balance test, Item G3: Sometimes residents are unwilling to participate, despite instruction and support. Will surveyors accept that the resident declined to participate? Should staff document extensively that the resident declined to participate?
A. In approaching a resident for a balance test or any assessment, staff should provide privacy and an explanation. The resident may, of course, decline the test but the facility should attempt to determine why the resident is refusing. Since this would affect the MDS response, it seems worthy of a short notation which may be written directly on the MDS form. Surveyors will accept individual residents declining to participate but will probably be suspicious if an unusual number of residents decline participation in this test.
Q. Is it possible to be on a medication (e.g., a diuretic or pain medication) without a diagnosis?
A. A resident should not be on a drug without a valid reason, e.g., symptomatology that justifies the use of the drug. Refer to the CFR 483.25 (I) (1) regarding "Unnecessary Drugs - General". Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is defined as a drug used without adequate indications for its use. Guidance to Surveyors call for surveyors to allow the facility the opportunity to provide a rationale for the use of the drug(s), and the facility may not justify the use of a drug solely on the basis of a doctor's order. F tag 329 includes the following note: "The unnecessary drug criterion of 'adequate indications for use' does not simply mean that the physician's order must include a reason for using the drug (although such order writing is encouraged)". This means there is not a valid clinical reason for use of the drug based on the survey team's evaluation of some, but not necessarily all, of the following: resident assessment, plan of care, reports of significant change, progress notes, laboratory reports, professional consults, drug orders, observation and interview of the resident, and other information.
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