NOT REQUIRED Myers Documentation requirement (s) RAI MANUAL B0700: Makes Self Understood

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1 RAI MANUAL B0700: Makes Self Understood 1. Assess using the resident s preferred language. 2. Interact with the resident. Be sure he or she can hear you or have access to his or her preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing or using cue cards. 3. Observe his or her interactions with others in different settings and circumstances. 4. Consult with the primary nurse assistant (over all shifts), if available, the resident s family, and speech-language pathologist. Coding Instructions Code 0, understood: if the resident expresses requests and ideas clearly. Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He or she may have delayed responses or may require some prompting to make self understood. Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet)., resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet). Code 3, rarely or never understood: if, at best, the resident s understanding is limited to staff interpretation of highly individual B0700 Makes Self Understood (CPS) Example(s) of the resident s verbal and/or non-verbal ability and degree of impairment to express or communicate requests, needs, opinions, and to conduct social conversation in his or her primary language whether in speech, writing, sign language, or a combination. **This Item is included as it demonstrates the importance of coding B0700 Correctly

2 RAI MANUAL SECTION C: COGNITIVE PATTERNS C0100: Should Brief Interview for Mental Status Be Conducted? 1. Determine the resident s short-term memory status by asking him or her: to describe an event 5 minutes after it occurred if you can validate the resident s response, or to follow through on a direction given 5 minutes earlier. 2. Observe how often the resident has to be re-oriented to an activity or instructions. 3. Staff members also should observe the resident s cognitive function in varied daily activities. 4. Observations should be made by staff across all shifts and departments and others with close contact with the resident. 5. Ask direct care staff across all shifts and family or significant others about the resident s shortterm memory status. 6. Review the medical record for clues to the resident s short-term memory during the look-back period. RAI MANUAL C0700: Short-term Memory OK Assessment and treatment of an underlying related medical problem (particularly if this is a new observation) or adverse medication effect, or possible evaluation for other problems with thinking additional nursing support at times frequent prompting during daily activities additional support during recreational activities. 1. Determine the resident s short-term memory status by asking him or her: to describe an event 5 minutes after it occurred if you can validate the resident s response, or to follow through on a direction given 5 minutes earlier. 2. Observe how often the resident has to be re-oriented to an activity or instructions. 3. Staff members also should observe the resident s cognitive function in varied daily activities. 4. Observations should be made by staff across all shifts and departments and others with close contact with the resident. 5. Ask direct care staff across all shifts and family or significant others about the resident s shortterm memory status. 6. Review the medical record for clues to the resident s short-term memory during the look-back period.

3 C0700 Short-Term Memory (CPS) Example(s) documenting an event or direction referencing a 5 minute time frame after it occurred validated by documenting the resident s response. The focus of the person-centered care plan should be to assess for additional support needed to optimize remaining function, and promoting as much social and functional independence as possible while maintaining health and safety. Does include: Example(s) documenting the lack of follow through on a direction given 5 minutes earlier.

4 RAI MANUAL D0500: Staff Assessment of Resident Mood (PHQ-9-OV ) Look-back period for this item is 14 days. 1. Interview staff from all shifts who know the resident best. Conduct interview in a location that protects resident privacy. 2. The same administration techniques outlined above for the PHQ-9 Resident Mood Interview (pages D-4 D-6) and Interviewing Tips & Techniques (pages D-6 D-8) should also be followed when staff are interviewed. 3. Encourage staff to report symptom frequency, even if the staff believes the symptom to be unrelated to depression. 4. Explore unclear responses, focusing the discussion on the specific symptom listed on the assessment rather than expanding into a lengthy clinical evaluation. 5. If frequency cannot be coded because the resident has been in the facility for less than 14 days, talk to family or significant other and review transfer records to inform the selection of a frequency code. D0500A-J, Column 2 Staff Assessment of Resident Mood (Symptom Frequency) Example(s) that demonstrates the resident s mood specific to each applicable D0500A-J mood including interventions. Daily documentation of frequency for each applicable mood occurrence.

5 RAI MANUAL E0200: Behavioral Symptom-Presence & Frequency 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period. E0200A (code 2 or 3) Physical Behavioral Symptoms directed toward others Example(s) of resident s physical behavioral symptoms directed toward others. Daily documentation reflecting the frequency of 4 days to daily occurrence(s) for each applicable physical behavioral symptom directed towards others.

6 RAI MANUAL E0800: Rejection of Care Presence & Frequency 1. Review the medical record. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period. 3. Review the record and consult staff to determine whether the rejected care is needed to achieve the resident s preferences and goals for health and well-being. 4. Review the medical record to find out whether the care rejection behavior was previously addressed and documented in discussions or in care planning with the resident, family, or significant other and determined to be an informed choice consistent with the resident s values, preferences, or goals; or whether that the behavior represents an objection to the way care is provided, but acceptable alternative care and/or approaches to care have been identified and employed. If the resident indicates that the intention is to decline or refuse, then ask him or her about the reasons for rejecting care and about his or her goals for health care and well-being. If the resident is unable or unwilling to respond to questions about his or her rejection of care or goals for health care and well-being, then interview the family or significant other to ascertain the resident s health care preferences and goals. E0800 (code 2 or 3) Rejection of Care Example(s) of resident s rejection of care (e.g., blood work, taking medications, ADL assistance) that is necessary to achieve the resident s values, preferences or goals. Daily documentation reflecting the frequency of 4 days to daily occurrence(s) for each applicable rejection of care occurrence.

7 RAI MANUAL G0110: Activities of Daily Living (ADL) Assistance 1. Review the documentation in the medical record for the 7-day look-back period. 2. Talk with direct care staff from each shift that has cared for the resident to learn what the resident does for himself during each episode of each ADL activity definition as well as the type and level of staff assistance provided. Remind staff that the focus is on the 7-day look-back period only. 3. When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed Mobility, observe what the resident is able to do without assistance, and then determine the level of assistance the resident requires from staff for moving to and from a lying position, for turning the resident from side to side, and/or for positioning the resident in bed. To clarify your own understanding and observations about a resident s performance of an ADL activity (bed mobility, locomotion, transfer, etc.), ask probing questions, beginning with the general and proceeding to the more specific. See page G-10 for an example of using probes when talking to staff. Example of a Probing Conversation with Staff 1. Example of a probing conversation between the RN Assessment Coordinator and a nursing assistant (NA) regarding a resident s bed mobility assessment: RN: Describe to me how Mrs. L. moves herself in bed. By that I mean once she is in bed, how does she move from sitting up to lying down, lying down to sitting up, turning side to side and positioning herself? NA: She can lay down and sit up by herself, but I help her turn on her side. RN: She lays down and sits up without any verbal instructions or physical help? NA: No, I have to remind her to use her trapeze every time. But once I tell her how to do things, she can do it herself. RN: How do you help her turn side to side? NA: She can help turn herself by grabbing onto her side rail. I tell her what to do. But she needs me to lift her bottom and guide her legs into a good position. RN: Do you lift her by yourself or does someone help you? NA: I do it by myself. RN: How many times during the last 7 days did you give this type of help? NA: Every day, probably 3 times each day. In this example, the assessor inquired specifically how Mrs. L. moves to and from a lying position, how she turns from side to side, and how the resident positions herself while in bed. A resident can be independent in one aspect of bed mobility, yet require extensive assistance in another aspect, so be sure to consider each activity definition fully. If the RN did not probe further, he or she would not have received enough information to make an accurate assessment of the actual assistance Mrs. L. received. This information is important to know and document because accurate coding and supportive documentation provides the basis for reporting on the type and amount of care provided. Coding: Bed Mobility ADL assistance would be coded 3 (self-performance) and 2 (support provided), extensive assistance with a one person ass

8 Functional Status (7-day look back) G0110A, Column 1&2 Bed Mobility G0110B, Column 1&2 Transfer G0110I, Column 1&2 Toilet Use G0110H, Column 1&2 Eating ~Extensive Services Documentation must reflect all episodes over each a 24-hour period during the observation period while a resident. *** Initials and dates to authenticate the ADL self-performance and support provided including signatures and titles to authenticate initials per episode. *** The ADL key for self-performance and support provided must include all the MDS key options and be equivalent to the intent and definition of the MDS key (key of 7 self-performance is optional). The ADL key for self-performance and support provided must be understood by and readily available to staff. ADL self-performance and support provided key definitions must be included in the electronic or hard copy ADL collection tool. ADL descriptions must include all tasks and components related to the specific ADL activity. If using narrative notes to support ADLs, each occurrence must include the specific ADL(s) and degree of self-performance and support provided. Wording must be equivalent to MDS key definitions for example extensive (weight-bearing) assist of one for transfers. *** Facility to designate one ADL documentation tool to be used for the entire review when more than one tool is used. ADL documentation must be maintained as part of the legal medical record and be readily accessible during the on-site review.

9 RAI MANUAL SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident s current health status. I: Active Diagnoses in the Last 7 Days There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period). 1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. I2000 *Pneumonia See Active Diagnoses Definition. Does NOT include: A hospital discharge note referencing pneumonia during hospitalization. *I2100 Septicemia See Active Diagnoses Definition. Does include: Sepsis Does NOT include: A hospital discharge note referencing septicemia during hospitalization.

10 RAI MANUAL J1100: Shortness of Breath (dyspnea) Planning for Care Shortness of breath can be an indication of a change in condition requiring further assessment and should be explored. The care plan should address underlying illnesses that may exacerbate symptoms of shortness of breath as well as symptomatic treatment for shortness of breath when it is not quickly reversible. Interview the resident about shortness of breath. Many residents, including those with mild to moderate dementia, may be able to provide feedback about their own symptoms. 1. If the resident is not experiencing shortness of breath or trouble breathing during the interview, ask the resident if shortness of breath occurs when he or she engages in certain activities. 2. Review the medical record for staff documentation of the presence of shortness of breath or trouble breathing. Interview staff on all shifts, and family/significant other regarding resident history of shortness of breath, allergies or other environmental triggers of shortness of breath. 3. Observe the resident for shortness of breath or trouble breathing. Signs of shortness of breath include: increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations and gasping for air at rest, interrupted speech pattern (only able to say a few words before taking a breath) and use of shoulder and other accessory muscles to breathe. 4. If shortness of breath or trouble breathing is observed, note whether it occurs with certain positions or activities. Coding Instructions Check all that apply during the 7-day look-back period. Any evidence of the presence of a symptom of shortness of breath should be captured in this item. A resident may have any combination of these symptoms. Check J1100A: if shortness of breath or trouble breathing is present when the resident is engaging in activity. Shortness of breath could be present during activity as limited as turning or moving in bed during daily care or with more strenuous activity such as transferring, walking, or bathing. If the resident avoids activity or is unable to engage in activity because of shortness of breath, then code this as present. Check J1100B: if shortness of breath or trouble breathing is present when the resident is sitting at rest. Check J1100C: if shortness of breath or trouble breathing is present when the resident attempts to lie flat. Also code this as present if the resident avoids lying flat because of shortness of breath. Check J1100Z: if the resident reports no shortness of breath or trouble breathing and the medical record and staff interviews indicate that shortness of breath appears to be absent or well controlled with current medication.

11 J1100C Shortness of Breath or Trouble Breathing When Lying Flat Documentation of the presence of or observation of shortness of breath or trouble breathing when lying flat during the observation period. Documentation might include signs and symptoms such as, but not limited to: 1) increased respiratory rate; 2) pursed lip breathing; 3) a prolonged expiratory phase; 4) audible respirations and gasping for air at rest; 5) interrupted speech pattern (only able to say a few words before taking a breath); and 6) use of shoulder and other accessory muscles to breath, OR Interventions to avoid shortness of breath while lying flat that are applied at all times or on an as needed basis must be documented daily when applicable. The focus of the person-centered care plan should address underlying cause(s) that may exacerbate symptoms of shortness of breath as well as symptomatic treatment for shortness of breath when it is not quickly reversible Does NOT include: General statements by the resident without actual observation or presence of symptoms of shortness of breath or interventions to alleviate shortness of breath.

12 RAI MANUAL K0300: Weight Loss Coding Instructions Mathematically round weights as described in Section K0200B before completing the weight loss calculation. Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician s order. In cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders for diuretics, K0300 can be coded as 1. DEFINITIONS PHYSICIAN-PRESCRIBED WEIGHT-LOSS REGIMEN A weight reduction plan ordered by the resident s physician with the care plan goal of weight reduction. May employ a calorie-restricted diet or other weight loss diets and exercise. Also includes planned diuresis. It is important that weight loss is intentional. *K0300 (code 1 or 2) Weight Loss Documentation supporting the expressed goal for the weight loss for code of 1, on physician-prescribed weight loss regimen.

13 RAI MANUAL M1030: Number of Venous and Arterial Ulcers Planning for Care The presence of venous and arterial ulcers should be accounted for in the interdisciplinary care plan. 1. Review the medical record, including skin care flow sheet or other skin tracking form. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any venous or arterial ulcers are present. Section M: Skin Conditions (7-day look back) M1030 Venous/Arterial Ulcers Description of the venous/arterial ulcer must include but is not limited to; identification of the wound as a venous/arterial ulcer,* location and dimensions. RAI MANUAL M1040: Other Ulcers, Wounds and Skin Problems 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any ulcers, wounds, or skin problems are present. M1040B Diabetic Foot Ulcer ~Special Care Low M1040C Other Open Lesion on the Foot, (e.g. cuts,fissures) Description of diabetic foot ulcer /open lesion must include but is not limited to location and dimensions

14 RAI MANUAL O0400: Therapies 1. Review the resident s medical record (e.g., rehabilitation therapy evaluation and treatment records, recreation therapy notes, mental health professional progress notes), and consult with each of the qualified care providers to collect the information required for this item. Coding Instructions for Respiratory, Psychological, and Recreational Therapies Total Minutes Enter the actual number of minutes therapy services were provided in the last 7 days. Enter 0 if none were provided. Days Enter the number of days therapy services were provided in the last 7 days. A day of therapy is defined as treatment for 15 minutes or more in the day. Enter 0 if therapy was provided but for less than 15 minutes every day for the last 7 days. If the total number of minutes during the last 7 days is 0, skip this item and leave blank. Respiratory Therapy Definition from RAI manual Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, nebulizer treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws. NOT REQUIRED Myers Documentation Requirement (s) O0400D2 Respiratory Therapy Days Physician order that includes a statement of treatment specific to the resident s needs. Documentation of actual direct minutes on a daily/shift/occurrence basis. Associated initials/signature(s) on a daily basis to support the total number of minutes of respiratory therapy provided. The services be reasonable and necessary for treatment of the resident s condition. Documentation that the respiratory nurse (licensed nurse) has been trained in the modalities provided either through formal nursing or specific training. Respiratory evaluation during the observation period by a licensed nurse. The focus of the person-centered care plan should include the necessity for, and the frequency and duration of the appropriateness of respiratory therapy.