COMMONWEALTH OF KENTUCKY OFFICE OF INSPECTOR GENERAL AND MYERS AND STAUFFER LC PRESENT ADVANCED TRAINING AND UPDATES

COMMONWEALTH OF KENTUCKY OFFICE OF INSPECTOR GENERAL AND MYERS AND STAUFFER LC PRESENT ADVANCED TRAINING AND UPDATES 1 MDS 3.0 VERSION 1.15.1 RAI MANUAL VERSION 1.15 Effective October 1, 2017 http://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html N0410H = Opioid N0450 = Antipsychotic Medication Review N0450A = Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? 0. No Antipsychotics were not received (Skip to next active section) 1. Yes - Antipsychotics were received on a routine basis (continue to N0450B) 2. Yes - Antipsychotics were received on a PRN basis only (continue to N0450B) 3. Yes - Antipsychotics were received on a routine and PRN basis (continue to N0450B) 2 MDS 3.0 VERSION 1.15.1 RAI MANUAL VERSION 1.15 N0450B = Has a gradual dose reduction (GDR) been attempted? 0. No (Skip to N0450D) 1. Yes (Continue to N0450C) N0450C = Date of last attempted GDR N0450D = Physician documented GDR as clinically contraindicated 0. No - GDR has not been documented by a physician as clinically contraindicated (Skip to next active section) 1. Yes - GDR has been documented by a physician as clinically contraindicated (Continue to N0450E) N0450E = Date physician documented GDR as clinically contraindicated P0200 = Alarms P0200A Bed alarm P0200B Chair alarm P0200C Floor mat alarm P0200D Motion sensor alarm P0200E Wander/elopement alarm P0200F Other alarm 3 1

RESIDENT ASSESSMENT INSTRUMENT Time required to complete the item set Item Set NP NOD NO/SO NSD NS/SS Estimated Response Time 51 MINUTES 39 MINUTES 26.52 MINUTES 34.17 MINUTES 14.03 MINUTES These times are estimated per response, including completion, encoding, and transmission of the information collection Page 2 of introduction 4 CHAPTER 1 RESIDENT ASSESSMENT INSTRUMENT (RAI) OVERVIEW 5 RESIDENT ASSESSMENT INSTRUMENT No significant changes 6 2

CHAPTER 2 ASSESSMENTS FOR THE RESIDENT ASSESSMENT INSTRUMENT (RAI) 7 ASSESSMENT TYPES AND DEFINITIONS Chapter 2; Section 2.5; Page 2-11 Footnote The Federal regulatory requirement at 42 CFR 483. 21(b)(2) A comprehensive care plan must be (ii) Prepared by an interdisciplinary team, that includes but is not limited to-the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or as requested by the resident, and, to the extent practicable, the participation of the resident and the resident s representative(s). 8 REQUIRED OBRA ASSESSMENTS FOR THE MDS Chapter 2; Section 2.6; Page 2-22 through 25 A significant change is a major decline or improvement in a resident s status. Decline in two or more of the following: Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment. Any decline in ADL, (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual s functioning. 9 3

REQUIRED OBRA ASSESSMENTS FOR THE MDS Chapter 2; Section 2.6; Page 2-25 through 26 A significant change is a major decline or improvement in a resident s status Decline in two or more of the following: Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in status. Resident begins to use a restraint of any type when it was not used before. Emergence of a condition/disease in which a resident is judged to be unstable. 10 REQUIRED OBRA ASSESSMENTS FOR THE MDS Chapter 2; Section 2.6; Page 2-26 A significant change is a major decline or improvement in a resident s status. Improvement in two or more of the following: Any improvement in ADL, (at least 1) where a resident is newly coded as Independent, Supervision, or Limited assistance since last assessment and does not reflect normal fluctuations in that individual s functioning. Resident's decision making improves. Resident's incontinence pattern improves. 11 REQUIRED OBRA ASSESSMENTS FOR THE MDS Chapter 2; Section 2.6; Page 2-30 A significant error is an error in an assessment where: 1. The resident s overall clinical status is not accurately represented on the erroneous assessment and/or results in an inappropriate plan of care; and 12 4

REQUIRED OBRA ASSESSMENTS FOR THE MDS Chapter 2; Section 2.6; Page 2-32 While the CAA process is not required with a noncomprehensive assessment (Quarterly, SCQA), nursing homes are still required to review the information from these assessments, and review and revise the resident s care plan. 13 THE CARE PLAN ASSESSMENT (CAA) PROCESS AND CARE PLAN COMPLETION Chapter 2; Section 2.7; Page 2-41..Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care (42 CFR 483.21 (a). 14 THE CARE PLAN ASSESSMENT (CAA) PROCESS AND CARE PLAN COMPLETION Chapter 2; Section 2.7; Page 2-42..However, the resident s care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Residents preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. 15 5

CHAPTER 3 MDS 3.0 ITEM BY ITEM 16 CHAPTER 3 INTRODUCTION Chapter 3; Page 3-3 through 6 With the exception of certain items, the lookback period does not extend into the preadmission period unless the item instructions state otherwise. In the case of reentry, the look-back period does not extend into time prior to the reentry, unless instructions state otherwise. Restraints and Alarms Record the frequency that the resident was restrained by any of the listed devices at any time during the day or night; record the frequency that any of the listed alarms were used. 17 SECTION A: IDENTIFICATION INFORMATION 18 6

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) (A1500) Chapter 3; Section 1500; Page A-18 All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual s payment source, must have a Level I PASRR completed. 19 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) OVERVIEW Chapter 3; Section 1500; Page A-18 All admissions to a Medicaid certified facility must have a Level I PASRR completed regardless of payment. Individuals who have or are suspected of having a diagnosis of MI or ID/DD or related conditions may not be admitted without Level II approval. Resident review (RR) is triggered whenever an individual undergoes a significant change in status (mental and/or physical) and that change has a material impact on their functioning as it relates to their MI/ID status: Required to contact your State mental health authority Ensures that individuals with serious mental illness or intellectual disability or related condition are not placed in a NF inappropriately. 20 SECTION G: FUNCTIONAL STATUS 21 7

ACTIVITIES OF DAILY LIVING (ADL) ASSISTANCE Chapter 3; Section G0110; Page-9 through 10 Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. Whether or not the resident holds onto a bar, strap, or other device during the full-body mechanical lift transfer is not part of the transfer activity and should not be considered as resident participation in a transfer. Transfers via lifts that require the resident to bear weight during the transfer, such as stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer and the lift provided weight-bearing support. 22 ACTIVITIES OF DAILY LIVING (ADL) ASSISTANCE Chapter 3; Section G0110; Page G-10 How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. When a resident is transferred into or out of bed or chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan or urinal is coded in G0110I, Toilet Use. 23 MOBILITY DEVICES (G0600) Chapter 3; Section G0600; Page G-40 C = Wheelchair If the resident normally sits in wheelchair when moving about. Include hand-propelled, motorized, or pushed by another person. Do not include gerichairs, reclining chairs with wheels, positioning chairs, scooters, and other types of specialty chairs. 24 8

GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-3 5. Section GG coding on admission should reflect the person s baseline admission functional status, and is based on a clinical assessment that occurs soon after the resident s admission. 25 GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-3 6. The admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission. If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. 26 GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-3 7. If the resident performs the activity more than once during the assessment period and the resident s performance varies, coding in Section GG should be based on the resident s usual performance A provider may need to use the entire 3-day assessment period to obtain the resident s performance. 27 9

GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-5 Admission or Discharge Performance Coding Tips Admission: slight wording changes-no impact Discharge: (as documented in A2400C, End of Most Recent Medicare Stay), either as a standalone assessment when the resident s Medicare Part A stay ends, but the resident remains in the facility; or may be combined with an OBRA Discharge if the Medicare Part A stay ends on the day of, or one day before the Discharge Date (A2000). 28 GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-5 Admission or Discharge Performance Coding Tips When coding the resident s usual performance, effort refers to the type and amount of assistance the helper provides in order for the activity to be completed. The 6- point rating scale definitions include the following types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance. 29 GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-6 Admission or Discharge Performance Coding Tips Clinicians may code the eating item using the appropriate response codes if the resident eats using his/her hands rather than using utensils. If the resident eats finger foods with his/her hands independently, for example, the resident would be coded as 06, Independent. 30 10

GG0130 SELF-CARE (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0130; Page GG-6 through 7 Admission or Discharge Performance Coding Tips Please note that a dash may be used for GG0130 Discharge Goal items provided that at least one Self-Care or one Mobility item has a Discharge Goal coded using the 6-point scale. Completion of the Self-Care items is not required if the resident has an unplanned discharge to an acute-care hospital, or if the SNF PPS Part A Stay is less than 3 days. 31 GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-19 Steps for Assessment 3. For the purposes of completing Section GG, a helper is defined as facility staff who are direct employees and facility-contracted employees (e.g., rehabilitation staff, nursing agency staff). Thus, does not include individuals hired, compensated or not, by individuals outside of the facility s management and administration, such as hospice staff, nursing/certified nursing assistance students, etc. 32 GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-19 through 20 Steps for Assessment 5. Section GG coding on admission should reflect the person s baseline admission functional status, and is based on a clinical assessment that occurs soon after the admission. 6. Repeat from slide 26 7. Repeat from slide 27 33 11

GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-22 Admission or Discharge Performance Coding Tips The turns included in the items GG0170J and GG0170R (walking or wheeling 50 feet with 2 turns) are 90-degree turns. The turns may be in the same direction (..) or may be in different directions (..). The 90-degree turn should occur at the person s ability level and can include use of an assistive device (for example, cane or wheelchair). 34 GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-38 Coding Tips for GG0170R and GG0170S, Wheelchair Items The intention of the wheelchair items is to assess the resident s use of a wheelchair for selfmobilization at admission and discharge when appropriate. The clinician uses clinical judgment to determine if the resident s use of a wheelchair is appropriate for self-mobilization due to the resident s medical condition or safety. 35 GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-38 Coding Tips for GG0170R and GG0170S, Wheelchair Items Do not code wheelchair mobility if the resident only uses a wheelchair when transported between locations within the facility. Only code wheelchair mobility based on an assessment of the resident s ability to mobilize in the wheelchair. 36 12

GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-39 Coding Tips for GG0170R and GG0170S, Wheelchair Items If the resident walks and is not learning how to mobilize in a wheelchair, and only uses a wheelchair for transport between locations within the facility, code the wheelchair gateway items at admission and/or discharge items GG0170Q1 and/or GG0170Q3.. 37 GG0170 MOBILITY (3-DAY ASSESSMENT PERIOD) ADMISSION/DISCHARGE (START/END OF MEDICARE PART A STAY) Chapter 3; Section GG0170; Page GG-39 Coding Tips for GG0170R and GG0170S, Wheelchair Items Admission assessment for wheelchair items should be coded for residents who used a wheelchair prior to admission or are anticipated to use a wheelchair during the stay, even if the resident is anticipated to ambulate during the stay or by discharge. The responses for gateway admission and discharge walking items (GG0170H1 and GG0170H3) and the gateway wheelchair items (GG0170Q1 and GG01070Q3) do not have to be the same on the admission and discharge assessments. 38 SECTION H: BLADDER & BOWEL 39 13

APPLIANCES (H0100) Chapter 3; Section H0100; Page H-3 D = Intermittent catheterization Self-catheterizations that are performed by the resident in the facility should be coded as intermittent catheterization (H0100D). This includes self-catheterization using clean technique. 40 SECTION I: ACTIVE DIAGNOSIS 41 ACTIVE DIAGNOSES-URINARY TRACT INFECTION (UTI) (LAST 30 DAYS) Chapter 3: Section I2300; Page I-8 ---Code only if both of the following are met in the last 30 days: 1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days. AND 2. A physician documented UTI diagnosis (or by nurse practitioner, etc.) in the last 30 days. 42 14

ACTIVE DIAGNOSES-URINARY TRACT INFECTION (UTI) (LAST 30 DAYS) Chapter 3: Section I2300; Page I-9 ---In accordance with requirements at 483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing, interpretation, and dissemination of surveillance data to identify infections. The facility s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident Resources for evidence-based UTI criteria are available on page I-9 of the RAI manual 43 SECTION J: HEALTH CONDITIONS 44 FALL HISTORY ON ADMISSION/ENTRY OR REENTRY (J1700) Chapter 3; Section J1700; Page 27 Fall Definition: CMS understands that challenging a resident s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls. 45 15

SECTION L: ORAL/DENTAL STATUS 46 DENTAL (L0200) Chapter 3: Section L0200: Page L-1 Edentulous Having no natural permanent teeth in the mouth. Complete tooth loss. Chapter 3: Section L0200; Page L-3 Coding tips: The dental status for a resident who has some, but not all, of his/her natural teeth that do not appear damaged and who does not have any other conditions in L0200A-G, should be coded in L0200Z, none of the above. 47 DENTAL (L0200) Chapter 3: Section L0200: Page L-3 Coding tips: Many residents have dentures or partials that fit well and work properly. However, for individualized care planning purposes, consideration should be taken for these residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly or meals, snacks, medication pass, and social activities. Additionally, the dentures or partials should be properly cared for with regular cleaning and by assuring that they continue to fit properly throughout the resident s stay. 48 16

SECTION M: SKIN CONDITIONS 49 UNHEALED PRESSURE ULCER(S) (M0210) Chapter 3; Section M0210: Page M-5 Coding Tips Oral mucosal ulcers caused by pressure should not be coded in Section M Code in item L0200C, Abnormal mouth tissue Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes, urinary catheters, etc.) should not be coded here. 50 CURRENT NUMBER OF UNHEALED PRESSURE ULCERS AT EACH STAGE (M0300) Chapter 3; Section M0300: Page M-7 Step 3: Determine Present on Admission 4. If the pressure ulcer was unstageable on admission/entry or reentry, but becomes numerically stageable later, it should be considered as present on admission at the stage at which it first becomes numerically stageable. 51 17

STAGE 3 PRESSURE ULCERS Chapter 3; Section M0300C: Page M-13 Coding tips In contrast, areas of significant adiposity can develop extremely deep Stage 3 pressure ulcers. Therefore, observation and assessment of skin folds should be part of overall skin assessment. Do not code moisture-associated skin damage or excoriation here. 52 OTHER ULCERS, WOUNDS AND SKIN PROBLEMS (M1040) Chapter 3; Section M1040D: Page M-36 Do not code pressure ulcers, venous or arterial ulcers, diabetic foot ulcers or skin tears here. These conditions are coded in other items on the MDS. 53 SECTION N: MEDICATIONS 54 18

MEDICATIONS RECEIVED (N0410) 55 MEDICATIONS RECEIVED (N0410) Chapter 3; Section N0410; Page N-7 N0410 H, Opioid Record the number of days am opioid medication was received by the resident at any time during the 7-day look-back period. 56 MEDICATIONS RECEIVED (N0410) Chapter 3; Section N0410; Page N-7 Coding Tips and Special Populations Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used. 57 19

MEDICATIONS RECEIVED (N0410) Chapter 3; Section N0410; Page N-8 Coding Tips and Special Populations In circumstances where reference materials vary in identifying a medication s therapeutic category and/or pharmacological classification, consult the resources/links cited in this section or consult the medication package insert, which is available through the facility s pharmacy or the manufacturer s website. 58 MEDICATIONS RECEIVED (N0410) Chapter 3; Section N0410; Page N-10 Coding Tips and Special Populations Opioid medications can be an effective intervention in a resident s pain management plan, but also carry risks such as overuse and constipation. A thorough assessment and root-cause analysis of the resident s pain should be conducted prior to initiation of an opioid medication and re-evaluation of the resident s pain, side-effects, and medication use and plan should be ongoing. 59 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-11 60 20

ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-11 61 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-12 Steps for Assessment 1. Review the resident's medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment. 2. If the resident received an antipsychotic medication, review the medical record to determine if a gradual dose reduction has been attempted. 3. If a gradual dose reduction was not attempted, review the medical record to determine if there is physician documentation that the GDR is clinically contraindicated. 62 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-12 Coding Instructions for N045A 1. Code 0, no: if antipsychotic were not received: Skip to O0100 2. Code 1, yes: if antipsychotic were received on a routine basis only: Continue to N0450B 3. Code 2, yes: if antipsychotics were received on a PRN basis only: Continue to N0450B 4. Code 3, yes: if antipsychotics were received on a routine and PRN basis: Continue to N0450B 63 21

ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-12 Coding Instructions for N045B 1. Code 0, no: if a GDR has not been attempted: Skip to N0450D 2. Code 1, yes: if a GDR has been attempted: Continue to N0450C Coding Instructions for N045C Enter the date of the last Gradual Dose Reduction. 64 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-13 Coding Instructions for N045D Code 0, no: if a GDR has not been documented by a physician as clinically contraindicated: Skip to O0100 Code 1, yes: if a GDR has been documented by a physician as clinically contraindicated: Continue to N0450E Coding Instructions for N045E Enter date the physician documented GDR attempts as clinically contraindicated. 65 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-13 Coding Tips and Special Populations Any medication that has a pharmacological classification or therapeutic category as an antipsychotic medication must be recorded in this section, regardless of why the medication is being used. Do not include Gradual Dose Reductions that occurred prior to admission to the facility. Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rationale for why an attempted dose reduction is inadvisable. 66 22

ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-13 Coding Tips and Special Populations Cont: This decision should be based on the fact that tapering of the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident s function, well-being, safety, and quality of life. Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated antipsychotic medication, the facility must attempt a GDR in two separate quarters, unless physician documentation is present in the medical record indicating a GDR is clinically contraindicated. 67 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-13 Coding Tips and Special Populations Cont: After the first year, a GDR must be attempted at least annually, unless clinically contraindicated. Do not count an antipsychotic medication taper performed for the purpose of switching the resident from one antipsychotic medication to another as a GDR in this section. 68 ANTIPSYCHOTIC MEDICATION REVIEW (N0450) Chapter 3; Section N0450; Page N-13 Coding Tips and Special Populations In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C. If multiple dose reductions have been attempted since admission/entry or reentry or the prior OBRA assessment, record the date of the most recent reduction attempt in N0450C. 69 23

SECTION O: SPECIAL TREATMENTS, PROCEDURES AND PROGRAMS 70 PNEUMOCOCCAL VACCINE (O0300) Chapter 3; Section O0300; Page O-13 If a resident has received one pneumococcal vaccination and it has been less than one year since the resident received the vaccination, he/she is not yet eligible for the second pneumococcal vaccination; therefore, O0300A is coded as 1, yes, indicating the resident s pneumococcal vaccination is up to date. 71 THERAPIES (O0400) Chapter 3; Section O0400; Page O-19 Respiratory therapy only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the RT or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes. 72 24

SECTION P: RESTRAINTS 73 ALARMS (P0200) Chapter 3; Section P0200; Page P-9 Planning for Care Individualized, person-centered care planning surrounding the resident's use of an alarm is important to the resident s overall well-being. When the use of an alarm is considered as an intervention in the resident s safety strategy, use must be based on the assessment of the resident and monitored for efficacy on an ongoing basis, including the assessment of unintended consequences of the alarm use and alternative interventions. These are times when the use of an alarm may meet the definition of a restraint, as the alarm may restrict the resident s freedom of movement and may not be easily removed by the resident. 74 ALARMS (P0200) Chapter 3; Section P0200; Page P-9 Steps for Assessment Review the resident s medical record to determine if alarms were used during the 7-day look-back. Consult the nursing staff to determine the resident s cognitive and physical status/limitations. Evaluate whether the alarm affects the resident s freedom of movement when the alarm/device is in place. For example, does the resident avoid standing up or repositioning himself/herself due to fear of setting off the alarm? 75 25

ALARMS (P0200) Chapter 3; Section P0200; Page P-2 76 ALARMS (P0200) Chapter 3; Section P0200; Page P-9 Coding Instructions Identify all alarms that were used at any time (day or night) during the 7-day look-back period. Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period. 77 ALARMS (P0200) Chapter 3; Section P0200; Page P-9 Coding Tips Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident s clothing. Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident s clothing. Floor mat alarm includes devices such as a sensor pad placed on the floor beside the bed. Motion sensor alarm includes infrared beam motion detectors. 78 26

ALARMS (P0200) Chapter 3; Section P0200; Page P-10 Coding Tips Wandering/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident s assistive device or other belongings. Other alarm includes devices such as alarms on the resident's bathroom and/or bedroom door, toilet seat alarms, or seatbelt alarms. 79 ALARMS (P0200) Chapter 3; Section P0200; Page P-10 Coding Tips Code any type of alarm, audible or inaudible, used during the look-back period in this section. If an alarm meets the criteria as a restraint, code the alarm use in both P0100, Physical Restraints, and P0200, Alarms. Motion sensors and wrist sensors worn by the resident to track the resident s sleep patterns should not be coded here in this section. 80 ALARMS (P0200) Chapter 3; Section P0200; Page P-10 Coding Tips Wandering is random or repetitive locomotion. This movement may be goal-directed or may be non-goal directed or aimless. Non-goal directed wandering requires a response in a matter that addresses both safety issues and an evaluation to identify root causes to the degree possible. While wander, door, or building alarms can help monitor a resident s activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. 81 27

ALARMS (P0200) Chapter 3; Section P0200; Page P-10 Coding Tips Bracelets or devices worn or attached to the resident and/or his or her belongings that signal a door to lock when the resident approaches should be coded in P0200F, Other Alarm, whether or not the device activates a sound. Do not code a universal building exit alarm applied to an exit door that is intended to alert staff when anyone (including visitors or staff members) exits the door. 82 SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING 83 PARTICIPATION IN ASSESSMENT (Q0100) Chapter 3; Section Q0100; Page Q-3 Coding Tips While family, significant others, or, if necessary, the guardian or legally authorized representative can be involved, the response selected must reflect the resident s perspective if he or she is able to express it, even if the opinion of the family member/significant other or guardian/legally authorized representative differs. 84 28

RESIDENT S OVERALL EXPECTATION (Q0300) Chapter 3; Section Q0300; Page Q-4 Steps for Assessment 1. Ask the resident about his/her overall expectations to be sure that he/she has participated in the assessment process and has a better understanding of his/her current situation and the implications or alternative choices, such as returning home, or moving to another appropriate community setting such as an assisted living facility or an alternative healthcare setting. 85 RESIDENT S OVERALL EXPECTATION (Q0300) Chapter 3; Section Q0300; Page Q-5 Coding Tips This item is individualized and resident-driven rather than what the nursing home staff judge to be in the best interest of the resident. This item focuses on exploring the resident s expectations, not whether or not staff considers them to be realistic. Coding other than the resident s stated expectation is a violation of the resident s civil rights. 86 DISCHARGE PLAN (Q0400) Chapter 3; Section Q0400; Page Q-10 Should a planned relocation not occur, it might create stress and disappointment for the resident and family that will require support and nursing home care planning interventions. However, a referral should not be avoided based upon facility staff judgement of potential discharge success or failure. It is the resident's right to be provided information if requested and to receive care in the most integrated setting. 87 29

RESIDENT S PREFERENCE TO AVOID BEING ASKED QUESTION Q0500B (Q0490) Chapter 3; Section Q0490; Page Q-12 Item Rationale.. Q0500B is, however, mandatory on all comprehensive assessments. Note: Let the resident know that they can change their mind about requesting information regarding possible return to the community at any time and should be referred to the LCA if they voice this request, regardless of schedule of MDS assessment(s). 88 CHAPTER 4 CARE AREA ASSESSMENT (CAA) PROCESS AND CARE PLANNING 89 THE RAI AND CARE PLANNING Chapter 4: Section 4.7; Page 10 through 11 The overall care plan should be oriented towards: 1. Assisting the resident in achieving his/her goals. 2. Individualized interventions that honor the resident s preferences. 3. Addressing ways to try to preserve and build upon resident strengths. 12. Assessing and planning for care to meet the resident s goals, preferences, and medical, nursing, mental and psychosocial needs. 13. Involving direct care staff with the care planning process relating to the resident s preferences, needs and expected outcomes. 90 30

CAA TIPS AND CLARIFICATIONS Chapter 4; Section 4.8; Page 4-12 CAA Tips and Clarifications 6) The resident s care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 7) Resident's preferences and goals may change throughout their stay, so facilities should be ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. 91 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS 3.0 VERSION 1.16.0 PROPOSED FOR Resident Classification System-1 (RCS-1) April 27, 2017, a Summary of Advance Notice was published in the Federal Register titled Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities: Revisions to Case-Mix Methodology. This proposed model would replace the current Resource Utilization Group, Version IV (RUG-IV). 93 31

MDS 3.0 VERSION 1.16.0 PROPOSED FOR Goals for developing an alternative payment system include: Creating a model that compensates SNFs accurately based on the complexity of the beneficiaries they serve and the resources necessary in caring for those beneficiaries. Address CMS concerns, along with those of OIG and MedPAC, about current incentives for SNFs to deliver therapy to beneficiaries based on financial considerations, rather than the most effective course of treatment for beneficiaries. Maintaining simplicity by, to the extent possible, limiting the number and type of elements we use to determine casemix, as well as limiting the number of assessments necessary under the payment system. 94 MDS 3.0 VERSION 1.16.0 PROPOSED FOR The RCS-1 case-mix will provide a single payment based on clinical characteristics in five areas: 1. PT and OT 2. SLP 3. Nursing 4. Non-Therapy Ancillary 5. Non-Case Mix 95 MDS 3.0 VERSION 1.16.0 PROPOSED FOR Physical Therapy and Occupational Therapy Will be assigned to one of 30 case-mix groups. Groups are determined by clinical reason* for the SNF stay; function score based on only selfperformance items in areas of transfer, eating and toileting; and the presence of moderate or severe cognitive impairment, potentially scored using the Cognitive Function Scale (CFS) which incorporates both BIMS and CPS scores. *Clinical categories include: Major Joint Replacement or Spinal Surgery, Other Orthopedic, Non-Orthopedic Surgery, Acute Neurologic, and Medical Management. 96 32

MDS 3.0 VERSION 1.16.0 PROPOSED FOR Speech-Language Pathology Will be assigned to one of 18 case-mix groups. Group will be determined by clinical reason* for the SNF stay, presence of a swallowing disorder or mechanically altered diet, and the presence of an SLP-related comorbidity or mild to severe cognitive impairment. *Clinical categories include: Acute Neurologic or Non-Neurologic. 97 MDS 3.0 VERSION 1.16.0 PROPOSED FOR Nursing Will be assigned to one of 43 case-mix groups potentially using the existing non-rehabilitation RUGs for the purpose of resident classification. Refinement for nursing in the case-mix model will be appropriate to better differentiate patient specific nursing resource needs. 98 MDS 3.0 VERSION 1.16.0 PROPOSED FOR Non-Therapy Ancillary Will be assigned to one of six Non-Therapy Ancillary (NTA) case-mix groups. Current cost regressions show that certain comorbidity conditions and extensive services are highly predictive of resident NTA costs. Considerations include basing a residents NTA score on a weighted count methodology. 99 33

MDS 3.0 VERSION 1.16.0 PROPOSED FOR Non-Case Mix Covers room and board Administrative costs Capital-related costs 100 MDS 3.0 VERSION 1.16.0 PROPOSED FOR RCS-1 will likely have impacts on the MDS schedule Consideration for using the 5-day SNF PPS scheduled assessment to classify a resident under an RCS-1 model for the entire Part A stay. Consideration for using the Significant Change in Status Assessment (SCSA) to reclassify residents from the initial 5-day assessment classification for a significant change in function. Discharge assessment would likely continue continue to be required with additions to allow CMS to track therapy minutes across the Part A stay. 101 MDS 3.0 VERSION 1.16.0 PROPOSED FOR RCS-1 will likely have impacts on the MDS schedule Consideration for an interrupted stay policy in cases where a resident is discharge from a SNF and returns to the same SNF within three calendar days after having been discharged, with the possibility of treating the resident's stay as a continuation of the previous stay for purposes of both resident classification and the variable per diem adjustment schedule. 102 34

MDS 3.0 VERSION 1.16.0 PROPOSED FOR Modes of care will promote increased individualized therapy treatment Concurrent therapy may be limited to no more than 25% of a SNF resident s therapy minutes and may be therapy discipline specific. Group therapy alike may be limited to 25%, which is consistent with the existing limit. 103 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section GG GG0100 Prior Functioning: Everyday Activities. Includes the resident's usual ability with everyday activities prior to the current illness, exacerbation, or injury A. Self-care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to current illness. B. Indoor Mobility (Ambulation): Code the resident s need for assistance with walking from room to room (with or without a device) prior to current illness... 104 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section GG GG0100 Prior Functioning: Everyday Activities. Includes the resident's usual ability with everyday activities prior to the current illness, exacerbation, or injury C. Stairs: Code the resident s need for assistance with internal or external stairs (with or without a device) prior to current illness.. D. Functional Cognition: Code the resident s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to current illness 105 35

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section GG GG0100 Prior Functioning: Everyday Activities. Includes the resident's usual ability with everyday activities prior to the current illness, exacerbation, or injury Coding key for GG0100A, B, C, D 3. Independent Resident completed the activities by him/herself, with or without an assistive device, with no assistance for a helper. 2. Needed Some Help resident needed partial assistance from another person to complete activities. 1. Dependent A helper completed the activities for the resident. 8. Unknown 9. Not Applicable 106 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section GG GG0110 Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury Check all that apply: A. Manual wheelchair B. Motorized wheelchair and/or scooter C. Mechanical lift D. Walker E. Orthotics/Prosthetics F. None of the above 107 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0130 Self-Care Code the resident s usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s). 108 36

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0130 Self-Care From 6-point scale 4. Supervision or touch assistance Helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. 109 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0130 Self-Care If activity was not attempted, code the reason: 9. Not applicable Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints). 110 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0130 Self-Care A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid one the meal is placed before the resident. B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement 111 37

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section GG GG0130 Self-Care E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. 112 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0170 Self-Care Code the resident s usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s). 113 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0170 Self-Care From 6-point scale 4. Supervision or touch assistance Helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. 114 38

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section GG GG0170 Self-Care If activity was not attempted, code the reason: 9. Not applicable Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints). 115 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Changes: Section GG GG0170 Mobility A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. D. Added wheelchair to text. 116 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Changes: Section GG GG0170 Mobility G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Items deleted H1. Does the resident walk? H3. Does the resident walk? 117 39

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Changes: Section GG GG0170 Mobility I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission performance is coded 07, 09, 10, or 88 Skip to GG0170M Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If discharge performance is coded 07, 09, 10, or 88 Skip to GG0170M 118 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Changes: Section GG GG0170 Mobility L. Walk 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. N. 4 steps: The ability to go up and down four steps with or without a rail. O. 12 steps: The ability to go up and down 12 steps with or without a rail. P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. 119 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section I Section I0020. Indicate the resident s primary medical condition category that best describes the primary reason for admission Complete only if A0310B=01 1. Stroke 2. Non-Traumatic Brain Dysfunction 3. Traumatic Brain Dysfunction 4. Non-Traumatic Spinal Cord Dysfunction 5. Traumatic Spinal Cord Dysfunction 6. Progressive Neurological Conditions 7. Other Neurological Conditions 120 40

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section I Section I0020. Indicate the resident s primary medical condition category that best describes the primary reason for admission Complete only if A0310B=01 8. Amputation 9. Hip and Knee Replacement 10. Fractures and Other Multiple Trauma 11. Other Orthopedic Conditions 12. Debility, Cardiorespiratory Conditions 13. Medically Complex Conditions 14. Other Medical Condition (must enter ICD code) 121 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section J J2000. Prior Surgery Did the resident have major surgery during the 100 days prior to admission? Code 0. No Code 1. Yes Code 8. Unknown 122 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Section: Section K Section K0510 Nutritional Approaches New key item: 3. Performed during the first 3 days of admission Complete only if A0310B=01 123 41

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section O Section O0100 Special Treatments, Procedures, and Programs A. Chemotherapy (if checked, please specify below) A2a. IV A3a. Oral A10a. Other C. Oxygen Therapy (if checked, please specify below) C2a. Continuous C3a. intermittent 124 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section O Section O0100 Special Treatments, Procedures, and Programs D. Suctioning (if checked, please specify below) D2a. Scheduled D3a. As needed F. Invasive Mechanical Ventilator (ventilator or respirator) G. Non-invasive Mechanical Ventilator (if checked, please specify below) G2a. BiPAP G3a. CPAP 125 MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS Section Changes: Section O Section O0100 Special Treatments, Procedures, and Programs H. IV Medications (if checked, please specify below) H3a. Antibiotics H4a. Anticoagulation H10a. Other J. Dialysis (if checked, please specify below) J2a. Hemodialysis J2b. Hemodialysis received in facility, in an ESRD certified unit J2c. Hemodialysis received in facility, not in an ESRD certified unit J2d. Hemodialysis received outside of facility J3a. Peritoneal dialysis 126 42

MDS 3.0 VERSION 1.16.0 PROPOSED FOR MDS NEW Item: Section O Section O0100 Special Treatments, Procedures, and Programs O. IV Access (if checked, please specify below) O2a. Peripheral IV O3a. Midline O4a. Central line (e.g., PICC, tunneled, pot) O10A. Other 127 SECTION G: FUNCTIONAL STATUS 128 ACTIVITIES OF DAILY LIVING (ADL) ASSISTANCE (G0110) This section involves a two-part ADL evaluation: Self-Performance, which measures how much of the ADL the resident can do for self. Support-Provided, which measures how much facility staff support is needed for the resident to complete the ADL. Each section uses its own scale. Recommended the Self-Performance evaluation be completed for all ADL activities before beginning the Support evaluation. 129 43

ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 3 or More Times: Code 0 = Independent, no help or staff oversight at any time Code 1 = Supervision, oversight, encouragement, or cueing Code 2 = Limited assistance: Resident highly involved in activity Staff provide guided maneuvering of limbs or other non-weight-bearing assistance: Guided maneuvering vs. weight-bearing is determined by who is supporting the weight of the resident s extremity or body. 130 ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 3 or More Times: Code 3 = Extensive assistance: Resident performed part of activity Staff provide weight-bearing support, OR Full staff performance part but not all of the time Code 4 = Total dependence: Full staff performance every time during entire 7- day period No participation by resident for any part of ADL activity 131 ADL SELF-PERFORMANCE CODING (G0110 COLUMN 1) Activity Occurred 2 or Fewer Times: Code 7 = Activity occurred only once or twice Code 8 = Activity did not occur: Activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. For more explanation please watch: CMS youtube video for Section G: http://youtu.be/t-6e5nv4j6k 132 44

ACTIVITIES OF DAILY LIVING (G0110) RULE OF 3 INSTRUCTIONS FOR THE RULE OF 3 The Rule of 3 is a method that was developed to help determine the appropriate code to document ADL Self-Performance on the MDS. It is very important that staff fully understand the components of each ADL, the ADL Self- Performance coding level definitions and the Rule of 3. To properly apply the Rule of 3, the facility must note which activities occurred, how many times, what type and what level of support was required over the 7-day observation period. 134 INSTRUCTIONS FOR THE RULE OF 3 Apply the steps of the Rule of 3 before using the algorithm for the Rule of 3. These steps must be followed in sequential order. Apply the first rule that meets the coding scenario. Start by counting the number of episodes at each ADL Self-Performance Level. 135 45

INSTRUCTIONS FOR THE RULE OF 3 4 4 8 1 1 0 0 Code of Exceptions to the Rule of 3: 136 INSTRUCTIONS FOR THE RULE OF 3 8 8 8 8 8 8 8 8 4 8 8 8 8 8 8 8 8 8 8 8 8 Code of Exceptions to the Rule of 3: 137 INSTRUCTIONS FOR THE RULE OF 3 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Code of Exceptions to the Rule of 3: 138 46

INSTRUCTIONS FOR THE RULE OF 3 4 1 0 4 3 2 2 2 3 0 Rule 1: Code of 139 INSTRUCTIONS FOR THE RULE OF 3 0 4 2 2 0 2 2 1 3 4 1 1 3 1 1 2 0 1 2 0 0 Rule 2: Code of 140 INSTRUCTIONS FOR THE RULE OF 3 Rule 3: 3. When an activity occurs three (3) or more times and at multiple levels, but NOT three (3) times at any one level, apply the following in sequence as listed stop at the first level that applies: (NOTE: This 3 rd rule ONLY applies if there are NOT any levels that are 3 or more episodes at any one level. DO NOT proceed to 3a, 3b or 3c unless this criteria is met) 141 47

INSTRUCTIONS FOR THE RULE OF 3 4 8 4 4 8 8 4 0 0 0 0 0 0 0 2 2 2 0 3 2 0 Rule 3a: Code of 142 INSTRUCTIONS FOR THE RULE OF 3 4 8 8 2 8 8 8 8 3 2 0 1 0 4 8 8 3 8 8 1 8 Rule 3b: Code of 143 INSTRUCTIONS FOR THE RULE OF 3 4 1 0 2 2 0 1 3 Rule 3c: Code of 144 48

INSTRUCTIONS FOR THE RULE OF 3 If none of the above are met, code Supervision (1) 145 EXAMPLE #1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 0 2 2 0 Applicable Rule of 3 Code of 146 EXAMPLE #2 3 0 1 2 0 0 2 0 4 0 0 1 0 4 0 0 0 0 3 0 0 Applicable Rule of 3 Code of 147 49

EXAMPLE #3 0 4 2 2 0 2 2 1 3 4 1 1 3 1 1 2 0 1 2 0 0 Applicable Rule of 3 Code of 148 EXAMPLE #4 3 0 0 0 0 0 2 0 0 8 0 2 0 0 8 8 8 8 8 8 8 Applicable Rule of 3 Code of 149 EXAMPLE #5 4 3 2 2 1 1 0 Applicable Rule of 3 Code of 150 50

EXAMPLE #6 8 8 8 8 8 8 8 0 0 0 0 0 0 0 8 0 2 4 2 0 8 Applicable Rule of 3 Code of 151 TIME-WEIGHTED CMI RESIDENT ROSTER REPORT OVERVIEW BASIC OBRA ASSESSMENT/RECORD SEQUENCE REQUIREMENTS Federal regulations 42 CFR 483.20(b)(1)(xviii), (g), and (h) 1) Assessment accurately reflects resident status 2) RN conducts/coordinates each assessment including appropriate health professionals 3) Includes direct observation AND communication with resident and staff on all shifts 4) Required of Medicare certified, Medicaid certified or both 5) Must conduct initial and periodic assessments 153 51

BASIC SEQUENCING REQUIREMENTS OF OBRA ASSESSMENTS/RECORDS 1) Tracking records a) Entry Tracking Type of entry (A1700) b) Death in Facility 2) Admission assessment within 14 days of admission 3) Comprehensive assessment every 366 days 4) Non-comprehensive assessment every 92 days 5) Discharge assessment required when out of facility greater than 24 hours 6) ARD date used to determine next assessment completion 154 GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Time-Weighted CMI Resident Roster Report Provides information regarding the assessments/records transmitted Produced for the following periods January 1 to March 31 April 1 to June 30 July 1 to September 30 October 1 to December 31 155 GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Record Selection Assessment/record active on the first day of the quarter All other assessments/records completed within the quarter Transmitted before the cutoff date Target dates include A1600 entry date A2300 assessment reference date (ARD) A2000 discharge date 156 52

GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Transmission Cutoff Dates and CMI Report Posting Dates Quarter End Dates: Jan. March April June July Sept. Oct. Dec. First Preliminary Case Mix Report Cutoff Date March 31 June 30 Sept. 30 Dec. 31 Posting Date April 29 July 30 Oct. 30 Feb. 25 Second Preliminary Case Mix Report Cutoff Date April 30 July 31 Oct. 31 Jan. 31 Posting Date May 31 August 31 Nov. 30 Feb. 28 Final Case Mix Report Cutoff Date June 30 Sept. 30 Dec. 31 March 31 Posting Date July 29 Oct. 29 Jan. 29 April 29 157 GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Information Displayed on the CMI Report Resident name Resident ID number Record type (A0310A/B/F) Target date RUG classification Start date Start date field End date Number of active days during the quarter Case Mix Index (CMI) Payment source 158 GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Days Counted for the Time-Weighted CMI Resident Roster Report 1. From the first day of the quarter, OR 2. From the Entry (A1600) date to the day preceding the target date of the next assessment/record, OR 3. From the target date to the day preceding the target date of the next assessment/record, OR 4. From the target date through the last day of the quarter, OR 5. From the target date until the assessment/record is no longer considered active (i.e. delinquent), OR 6. From the target date to the day preceding the discharge date 159 53

GENERAL CONCEPTS OF TIME-WEIGHTED METHODOLOGY Time-Weighted Roster Guidelines Day of admission/entry (A1600) is counted Day of discharge (A2000) is never counted Assessments are active for a maximum of 113 days (for Medicaid purposes only) Delinquent days are assigned a BC1 classification and CMI of 0.48 beginning day 114 Federal and State regulations require an OBRA assessment be completed every 92 days 160 ROSTER REPORT FORMAT Kentucky Case Mix System Department for Medicaid Services Second Preliminary Time-Weighted Resident Listing for the Quarter 01/01/2017 03/31/2017 Records Received as of 04/30/2017 Provider Number: XXXXXXXXXXXX Provider Name: XXXXXXXXXXXXXXXXXXXXXX Start Resident Record Target RUG Start Date End Resident Name ID Type Date Class Date Field Date NAME Resid100 NT/99/99/01 01/03/17 01/03/17 A1600 01/03/17 Case Mix Days Index Payment Source NC/01/99/99 01/10/17 CC2 01/03/17 A1600 03/01/17 58 1.22 Medicaid ND/99/99/10 03/02/17 03/02/17 A2000 03/02/17 Total days 58 161 MAXIMUM NUMBER OF DAYS AN ASSESSMENT CONSIDERED ACTIVE Example 1: Delinquent assessment Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid101 NQ/02/99/99 10/14/16 SE2 01/01/17 02/03/17 34 1.91 Medicaid NQ/02/99/99 10/14/16 BC1 02/04/17 03/14/17 40 0.48 Medicaid NQ/02/99/99 03/15/17 SE2 03/15/17 03/31/17 17 1.91 Medicaid A2300 Total Days 91 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 March BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 162 54

MAXIMUM NUMBER OF DAYS AN ASSESSMENT CONSIDERED ACTIVE Example 2: Expired assessment ARD = 04/1/2016 Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid102 NC/03/99/99 04/01/16 BC1 01/01/17 03/31/17 91 0.48 Medicaid Total Days 91 Jan BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 Feb BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 March BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 163 ENTRY TRACKING RECORD Required upon every entry or reentry Time-weighted system will use the entry date (A1600) to begin counting days Type of entry (A1700) MUST be accurate Entry reason used to make report display decisions Entry Tracking record is not an assessment 164 ENTRY TRACKING RECORD Example 3: Entry date begins counting of days Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid103 NQ/02/99/99 11/15/16 CB1 01/01/17 01/05/17 5 0.99 Medicaid ND/99/99/11 01/06/17 01/06/17 A2000 01/06/17 NT/99/99/01 03/01/17 03/01/17 A1600 03/01/17 NC/01/99/99 03/13/17 PD2 03/01/17 A1600 03/31/17 31 0.95 Medicaid Total Days 36 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 165 55

ENTRY TRACKING RECORD Example 4: Entry tracking record not followed by another assessment but preceded by an active assessment State Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid104 NQ/02/99/99 12/30/16 SSA 01/01/17 01/05/17 5 1.41 Medicaid ND/99/99/11 01/06/17 01/06/17 A2000 01/06/17 NT/99/99/01 01/15/17 SSA 01/15/17 A1600 03/31/17 77 1.41 Medicaid Total Days 82 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 166 ADMISSION ASSESSMENT COMPLETION CRITERIA Resident s first stay, OR Resident returned after being discharged return not anticipated (Discharge/10), OR Resident returned after being discharged return anticipated (Discharge/11) but more than 30 days has lapsed 167 ADMISSION COMPLETION CRITERIA Example 5: Inclusion of the entry date and exclusion of the discharge date Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid105 NT/99/99/01 01/03/17 01/03/17 A1600 01/03/17 NC/01/99/99 01/11/17 01/03/17 A1600 03/01/17 CC2 59 1.22 Medicaid ND/99/99/11 03/02/17 03/02/17 A2000 03/02/17 Total days 59 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 168 56

ADMISSION COMPLETION CRITERIA Example 6: Admission assessment with more than 14 days between the entry date and the ARD date Entry date A1600 on the Entry tracking record = 01/12/2016 Entry date A1600 on the Admission assessment = 01/12/2016 ARD date A2300 = 01/24/2017 Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid106 NT/99/99/01 01/12/16 BC1 01/01/17 01/23/17 23 0.48 Medicaid NC/01/99/99 01/24/17 IB2 01/24/17 03/01/17 38 0.91 Medicaid A2300 ND/99/99/11 03/02/17 03/02/1 A2000 03/02/17 Total days 61 Jan BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 169 ADMISSION COMPLETION CRITERIA Example 7: Admission assessment is preceded by another RUGgable assessment Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid107 NQ/02/99/99 01/01/17 SSB 01/01/17 A2300 01/14/17 14 1.46 Medicaid NC/01/99/99 01/15/17 SE1 01/15/17 A2300 01/29/17 15 1.63 Medicaid NC/04/99/99 01/30/17 SE1 01/30/17 A2300 03/31/1 62 1.63 Medicaid Total Days 91 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 170 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Discharge Assessment/10 Return not Anticipated Discharge with no expectation of return If the resident returns, requires Entry tracking record Followed by Admission assessment 171 57

DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Discharge Assessment/11 Return Anticipated Discharge with expectation of return Entry tracking record must be completed If the resident returns more than 30 days later Entry tracking record Followed by Admission assessment 172 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Example 8: Sequential Discharge assessments Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid108 NQ/02/99/99 12/10/16 PB1 01/01/17 01/14/17 14 0.64 Other ND/99/99/11 01/15/17 01/15/17 01/15/17 A2000 ND/99/99/10 02/01/17 02/01/17 A2000 02/01/17 Total Days 14 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 173 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Entry/Discharge Condition When a RUG Classification is Applied Resident who entered and discharged prior to completing an initial Admission assessment Assessment will classify in one of the following RUG classifications (limited to 14 days) 174 58

DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Entry/Discharge Condition When a RUG Classification is Applied RUG assigned is based on the coding in section A2100, discharge status* SSB (CMI 1.46) classification where the reason for discharge was death or transfer to hospital (A2100 value of 03, 05, 08, or 09) CB1 (CMI 0.99) classification where the reason for discharge was other than death or transfer to hospital (A2100 value of 01, 02, 04, 06, 07, or 99) This scenario is active for a maximum of 14 days 175 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Discharge Status Key (A2100) 01. Community 02. Another nursing home 03. Acute hospital 04. Psychiatric hospital 05. Inpatient rehabilitation facility 06. ID/DD facility 07. Hospice 08. Deceased 09. Long Term Care hospital 176 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Entry/Discharge condition when a RUG classification is applied Example 9: An Entry tracking record and Discharge assessment (with no Admission assessment) Entry date A1600 = 12/25/2016 Discharge date A2000 = 01/07/2017 Discharge status A2100 = 03 Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid109 NT/99/99/01 12/25/16 SSB 01/01/17 01/06/17 6 1.46 Medicaid ND/99/99/10 01/07/17 01/07/17 01/07/17 A2000 Total Days 6 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 177 59

DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Entry Tracking Record is The Only Record Followed by a Discharge assessment There are more than 14 days between the entry date (A1600) and the discharge date (A2000) Days begin counting from the entry date (A1600) and continue counting until the 14 th day On the 15 th day, BC1 delinquent days begin counting 178 DISCHARGE ASSESSMENT DEFINITIONS AND ENTRY/DISCHARGE CONDITIONS Entry Tracking Record is The Only Record Example 10: More than 14 days between the entry date and the discharge date Entry date A1600 = 01/02/2017 Discharge date A2000 = 01/26/2017 Start Case Resident Record Target RUG Start Date End Mix Payment Resident Name ID Type Date Class Date Field Date Days Index Source NAME Resid110 NT/99/99/01 01/02/17 CB1 01/02/17 A1600 01/15/17 14 0.99 Medicaid NT/99/99/01 01/02/17 BC1 01/16/17 01/25/17 10 0.48 Medicaid ND/99/99/11 01/26/17 01/26/17 A2000 01/26/17 Total Days 24 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 BC1 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 179 CASE MIX REPORT SUMMARY PAGE 7 7 7 180 60

CASE MIX REPORT SUMMARY PAGE 181 DELINQUENCY REPORT - EXAMPLE 7 7 7 7 6 6 6 6 6 182 FACILITY REVIEW OF FIRST AND SECOND PRELIMINARY CMI RESIDENT ROSTER REPORTS The purpose of the period between the posting of the Preliminary Resident Rosters and the final transmission date (cutoff date) for the Final Resident Roster is to review the assessment listing for accuracy. Some review considerations might include: Determine if all the residents on the first day of the quarter or during the quarter are listed on the Resident Roster Determine if each resident is identified only once 183 61