1. For Surveyors January 28, 2016 10am-12pm

2.  A – obtains key information to uniquely identify each resident, the home where they reside and the reasons for the assessment Important items are; Language, Marital Status, preferred name to be called & occupation Assessment Reference Date (ARD) (A2300) – this date is also located at the top right hand corner of each page of the MDS  B – documents the resident’s ability to hear, understand, & communicate with others & if there are visual limitations or difficulties to disease common in the elderly Important items are; Do they use a hearing aid, do they use corrective lenses

3.  C - determines the resident’s attention, orientation, & ability to register and recall new information. Very crucial in care planning decisions. Important items are; BIMS, Short-term & Long- term Memory, Decision Making  D – addresses mood Important items are; Resident Mood Interview – PHQ-9 & as Dr. Rider says this tool is not used as it should be  E – identifies behavioral symptoms Important items are; Behavioral Symptom - Presence & Frequency, Wandering

4.  F – gets the information regarding the resident’s preferences for their daily routine & activities This entire section is important. No one can take care of a resident if they don’t know their preferences  G – section assesses the need for assistance with ADLs, altered gait, balance, & decreased ROM Another important section. Need to understand the Rule of 3 when reviewing the ADLs

5.  When the activity occurred 3 or more times, code at that level  When the activity occurs 3 or more times at multiple levels, code the most dependent level that occurred 3 or more times unless it’s full staff assistance & that must occur every time  When the activity occurred 3 or more times & at multiple levels, but not 3 times at any 1 level, apply the following:

6.  Convert episodes of full staff performance to weight-bearing assistance, as long as full staff assistance did not occur every time.  When there is a combination of full staff performance & weight-bearing assistance that total 3 or more times – code extensive assist.  When there is a combination of full staff performance/weight-bearing assistance, &/or non-weight-bearing assistance that total 3 or more times – code limited assistance If none of the above are met, code supervision.

7. Limited assistLimited assist

8. LimitedExtensive Extensive

9. (Weight Bearing Assistance) Full Staff Performance (Not every time)Extensive Extensive (Weight Bearing Assistance)

10. Total DependenceExtensive (Full staff performance) Extensive Total DependenceExtensive (Full staff performance)

11. Total (Full staff performance) ExtensiveLimitedLimited (Weight-(Non-weightbearingassistance)

12. Supervision LimitedSupervision Extensive

13.  H – gathers information on the use of B&B appliances, toileting programs, continence, bowel patterns All of it is important  I – diseases are coded that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status  J – documents the number of health conditions that impact the resident’s functional status & quality of life Included in here is pain, shortness of breath, tobacco use, prognosis, problem conditions, falls

14.  K – assesses the many conditions that could affect the resident’s ability to maintain adequate nutrition & hydration. Important are; swallowing problems, weight loss, tube feeding  L – records any dental problems  M- documents the risk, presence, appearance, & change of PUs All of it is important  N – records number of days, during the last 7 days that any type of injection, insulin, &/or select meds were received

15.  O – identifies special treatments, procedures, & programs the resident received Important are; O2 therapy, trach, BiPAP, Dialysis, Hospice, etc, flu & pneumococcal vaccines, therapies & their minutes, restorative, physician examinations/orders  P – records a resident was restrained by any of the listed devices Important; need to determine if what they’re using fits the definition of a restraint – any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that they cannot remove easily, which restricts freedom of movement or normal access to their body

16.  Q – records the participation & expectations of the resident, family/significant other in the assessment & to understand their overall goals Important; who participated, overall expectation, discharge plan, return to community, referral  V – shows what care areas are triggered by MDS item responses that indicate the need for more assessment  X – identifies an MDS record to be modified or inactivated  Z – provides billing information

17.  Admission – day of admission is day1, complete by end of day 14, complete CAAs by end of day 14, complete care plan no later than 7 days after the CAAs completion date  Annual – must be completed at least within 366 days from the last comprehensive assessment ARD or within 92 days of the prior Quarterly assessment ARD  Quarterly – must be completed within 92 days from the prior assessment ARD. There must be at a minimum 3 Quarterlies in a 12 month period  These time frames only apply to OBRA assessments, not PPS.

18.  A Significant change is a decline or improvement in a resident’s status that: Will not normally resolve itself without intervention by staff Impacts more than one area of the resident’s health status; and Requires interdisciplinary review and/or revision of the care plan  When there’s a status change and it is not clear if this is a Sig Change, staff may take up to 14 days to determine if the criteria are met  Once a Sig Change is determined, the staff should document the initial identification of it in the medical record

19.  If there is only 1 change, staff may still decide to do a Sig Change. Remember each resident’s situation is unique and staff needs to decide if the resident would benefit from a Sig Change. They must document in the medical record their rationale for doing one when the criteria is not met.  Decline in 2 or more of the following: decision-making, change in mood, decline in ADL where resident is newly coded as Extensive/ Total dependence/Activity did not occur, incontinence pattern changes or they now have a foley, weight loss, new PU at Stage II or higher or a worsening of a current PU, begins to use a restraint, overall deterioration.

20.  Mr. B just recovered from the flu. Still had a poor appetite & needed more help with dressing/walking. On Wednesday it was noted he had a 5% weight loss in 30 days. IDT decided to see if he would improve over the weekend. On Monday, he had not lost any more weight, still needed more help with dressing/walking & now had a Stage II PU on coccyx. Due to the weight loss, decrease in ADLs & a PU a Sig Change was needed.  Mr. T no longer responds to verbal requests to alter his screaming. This occurs daily, has not lessened on it’s own or responded to treatment. He also resists care, pushes staff away during ALDs. A Sig Change is required because of the deterioration in his behavioral symptoms.  Mrs. G has been in facility for 5 weeks after being in hospital 8 weeks. On admission she was very frail, had trouble thinking, was confused & had many behavioral complications. With treatment she steadily improved & is now stable. She is no longer confused or exhibiting inappropriate behaviors. She is not the same person she was on admission. Her initial problems have resolved and she will remain in the facility. A Sig Change should be done.  Mrs. K has steadily improved since admission. The initial MDS set goals. Her care was modified as necessary to ensure improvement. She will discharge in 5 days. No Sig Change is needed.

21.  It cannot be completed prior to an Admission Assessment  It must be done when a resident goes on Hospice. The ARD must be within 14 days from the effective date of Hospice which can be the same or later than the date Hospice started, but not earlier. It must be completed on or before the 14 th day from going on Hospice  If a resident goes on Hospice during their first 14 days in the facility then checking the Hospice Care item, O0100K on the Admission Assessment takes the place of doing a Sig Change  One has to be done when a resident is DC’d from Hospice and when the Hospice agency changes. The ARD must be within 14 days from the date it stopped or when the agency changed.

22.  Complete only on following Assessments: ◦ A0310A.= 01. Admission; 03. Annual; 04. SCSA; 05. SCPCA  Resident with MI or ID (Intellectual Disability)/DD  PASRR report provided by state

23.  Code 0. No. If any of the following apply: ◦ Level I screening did not result in referral ◦ Level I screening determined resident does not have serious MI/ID/DD or related condition ◦ PASRR screening not required when:  Resident admitted from hospital after acute inpatient care AND  Receiving service for condition received care for in hospital AND  Attending physician certified before admission likely require <30 days of nursing home care ◦  Skip to A1550.

25. Definition: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body.  Any manual method or physical or mechanical devise, material or equipment should be classified as a restraint only when it meets the criteria of the restraint definition. This can only be determined on a case-by-case basis by individually assessing each & every manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body, & the effect it has on the resident.

26. Clarifications:  “Remove easily” means it can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g. side rails are put down, not climbed over, buckles are intentionally unbuckled, ties or knots are intentionally untied), considering the resident’s physical ability to accomplish their objective (e.g. transfer to a chair, get to the BR on time).  “Freedom of movement” means any change in place or position for the body or any part of the body that the person is physically able to control or access.

27.  Bed rails – any combination of partial or full rails (e.g. one-side half-rail, one-side full rail, two-side half-rails or quarter-rails, rails along the side of the bed that blocks ¾ to the whole length of the mattress top to bottom, etc.) Bed rails used as positioning devices. If the use of bed rails meet the definition of a restraint even though they may improve resident’s bed mobility, they must be coded as a restraint. Bed rails used by residents who are immobile. If the resident is immobile & cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the rails do not meet the definition. For residents who have no voluntary movement, the staff need to determine if there is an appropriate use of rails. Rails may create a visual barrier & deter physical contact from others.

28. Some residents have no ability to carry out voluntary movements, yet they exhibit involuntary movements. Involuntary movements, resident weight, & gravity effects may lead to their body shifting toward the edge of the bed. When rails are used in these cases, they could be at risk for entrapment. Clinical evaluation of alternatives (e.g. concave mattress), coupled with frequent monitoring of their position should be considered. While the rails may not constitute a restraint, they may affect the resident’s quality of life & create an accident hazard.

29.  Chair that prevents rising – any chair with a locked lap board, that places the resident in a recumbent position that restricts rising, chairs that are soft & low to the floor, that have a cushion in the seat that prohibits rising, geriatric chairs, & enclosed-frame wheeled walkers. For residents who can transfer from other chairs, but cannot transfer from a geriatric chair, this chair would be considered a restraint for that resident. For residents who cannot transfer independently, the geriatric chair does not meet the definition of a restraint. Geriatric chair used for residents who are immobile. For residents who have no voluntary or involuntary movement, the geriatric chair does not meet the definition. Enclosed-frame wheeled walkers are only a restraint if the resident cannot exit the walker via opening a gate, bar, strap, latch, removing a tray, etc.

30.  Q: We have a resident who constantly leans to side she is positioned on. She is high risk for falling out of bed. We’ve tried to reposition her when she is leaning beyond the edge of the wedge mattress, but didn’t have much success. She is 4/2 for bed mobility & 4/3 for transfers. We are putting the padded side rail up when she’s on her side. Is this a restraint?  A: The side rails are restraints only if they meet the definition of a restraint. The question is whether the side rails prevent the resident from voluntarily doing something that she can do when the device is not present. For example, if the resident can voluntarily get out of the bed when the side rail is not in place (which is not to be confused with falling out of the bed) but is unable to get out of the bed when the side rail is in place, then it is a restraint by the definition in the regulation. If your resident doesn't voluntarily swing her legs over the side of the bed or otherwise voluntarily exits the bed when there's no rail there, then this device is not a restraint in her case. Side rails may be a danger even to immobile residents. Care planning and care delivery should always take this into account.

31.  Admission – CAAs completion date must be no later than day 14 of the resident’s stay. So if the Admission ARD is set on day 14, the CAAs need to be done the same day.  Annual – CAAs completion date must be no later than 14 days after the ARD (ARD + 14 calendar days).  Significant Change in Status – CAAs completion date must be no later than 14 days after the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met.  Significant Correction to Prior Comprehensive Assessment – CAAs completion date must be no later than 14 days after the ARD (ARD +14 calendar days) and no more then 14 days after the determination was made that a significant error was made.

32.  Process framework – When implemented properly, the CAA process should help staff: Consider each resident as a whole, with unique characteristics & strengths that affect their capacity to function Identify areas of concern that may warrant interventions Develop, to the extent possible, interventions to help improve, stabilize, or prevent decline in physical, functional, & psychosocial well-being, in the context of the resident’s condition, choices, & preferences for interventions; and Address the need & desire for other important considerations, such as advanced care planning & palliative care; e.g. symptom relief & pain management

33.  Documentation – explains the basis for the care plan by showing how the IDT determined that the underlying causes, contributing factors, & risk factors were related to the care area condition for a specific resident; for example, the documentation should indicate the basis for these decisions, why the findings require an intervention, & the rationale for selecting specific interventions.

34. Relevant documentation for each triggered CAA describes: causes & contributing factors; The nature of the issue or condition (may include presence or lack of objective data & subjective complaints). In other words, what exactly is the issue/problem for this resident & why is it a problem; Complications affecting or caused by the care area for this resident; Risk factors related to the presence of the condition that affects the staff’s decision to proceed to care planning; Factors that must be considered in developing individualized interventions, including the decision to care plan or not to care plan various findings for the individual resident; The need for additional evaluation by the attending physician; The resources, or assessment tool used for decision-making, & conclusions that arose from doing the CAA.

35. In addition to identifying causes & risk factors that contribute to the resident’s care area issues or conditions, the CAA process may help: Identify & address associated causes & effects; Determine whether & how multiple triggered items are related; Identify a need to obtain additional medical, functional, psychosocial, financial, or other information about a resident’s condition that may be gotten from the resident, their family, physician, direct care staff, lab & diagnostic tests; Identify whether & how a triggered condition actually affects the residents’ function & quality of life, or whether the resident is at particular risk of developing the conditions; Review the resident’s situation with PCP, Med Director, NP, to try to identify links among causes & between causes & consequences, & to identify pertinent tests, consultations, & interventions Determine whether a resident could potentially benefit from rehab interventions Begin to develop an individualized care plan with objectives & timetables to meet a resident’s medical, functional, mental, & psychosocial needs as identified through the assessment.

36.  Now, by writing “see NN 3/12/14”, is that enough to cover all the documentation criteria?  How about copying & pasting the same information to all the triggered CAAs?  A good CAA is where staff has used their critical thinking, looked at every thing that can affect this care area & found the root cause of why this area triggered.

37. A well developed care plan:  Looks @ each resident as a whole human being with unique characteristics & strengths  Views the resident in distinct functional areas for the purpose of gaining knowledge about their functional status  Gives the team a common understanding of the resident  Re-groups the information gathered to identify possible issues &/or conditions that the resident may have  Provides additional clarity of potential issues &/or conditions by looking @ possible causes & risks  Develops & implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring & follow-up  Reflects the resident input & goals for health care  Provides information on how issues/conditions can be addressed to provide the highest practicable level of well-being  Re-evaluates the resident’s status @ prescribed intervals & modifies the care plan as necessary

38. The overall care plan should be oriented towards:  Preventing avoidable declines in functioning or clarify why another goal takes precedence, i.e. palliative approaches in end of life  Managing risk factors to the extent possible or indicating the limits of such interventions  Addressing ways to try to preserve & build on resident strengths  Applying current standards of practice  Evaluating treatment of measurable objectives, timetables & outcomes  Respecting resident’s right to decline treatment  Offering alternative treatments  Using an interdisciplinary approach to care plan development to improve the resident’s abilities  Involving resident, family & other representatives  Assessing & planning for care to meet the resident’s medical, nursing, mental & psychosocial needs  Involving the direct care staff  Addressing additional care planning areas that are relevant to meet the resident’s needs

39.  Care Plan goals should be measurable & include the subject, verb & time frame  Separate care plans are not necessary for each area that triggers a CAA.  A new care plan does not need to be developed after each SCSA, SCPA, or Annual. Instead the nursing home may revise an existing care plan using the results of the latest comprehensive assessment. Facilities should also evaluate the appropriateness of the care plan @ all times including after Quarterly assessments, modifying as needed.  Revisions need to be done whenever there’s a change in any area. The care plan must reflect the current status of the resident. All new doctor orders, acute episodes, changes in any area of functioning should be addressed on the care plan  The current care plan needs to be available to staff 24/7 as this is the map they use to care for the resident

40. MDS accuracy is important, but you should not spend a lot of time reviewing it to see if it is accurate. Some inaccurate coding will jump out @ you, such as falls, skin, weight changes, etc. These are big things that should be accurate, but don’t worry about nit picky little things.

41. Thank you! Shirley