MDS 3.0. Section G - Physical Functioning & Section O - Special Treatments and Procedures. for clients of:

MDS 3.0 Section G - Physical Functioning & Section O - Special Treatments and Procedures for clients of: www.teamtsi.com 800.765.8998 Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL 33607 800.275.6252 www.polaris-group.com

MDS 3.0 Part 3 Limited Copyright: April 2017, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH76a-Developed by Polaris Group www.polaris-group.com Page 1 of 99

MDS 3.0 Part 3 Post Test 1. Staff support in Section G documented on the MDS should include: a. The frequency that a staff member is available b. The least assistance the resident requires during the observation period c. The maximum level of Support the resident received during the observation window d. None of the above 2. When consider ADL coding, you can use support provided by non-facility staff? a. True b. False 3. Total Reimbursable Minutes includes the following: a. All Individual minutes b. All group minutes c. All concurrent minutes d. All of the above 4. Which of the following applies to therapy days and minutes in Section O: a. You can round units to minutes b. If two therapies are given in a day, only counts as one day total c. You cannot include evaluation time in minutes d. All of the above FH76a-Developed by Polaris Group www.polaris-group.com Page 2 of 99

MDS 3.0 Part 3 Post Test Answers 1. Staff support in Section G documented on the MDS should include: a. The frequency that a staff member is available b. The least assistance the resident requires during the observation period c. The maximum level of Support the resident received during the observation window d. None of the above C 2. When consider ADL coding, you can use support provided by non-facility staff? a. True b. False F 3. Total Reimbursable Minutes includes the following: a. All Individual minutes b. All group minutes c. All concurrent minutes d. All of the above 4. Which of the following applies to therapy days and minutes in Section O: a. You can round units to minutes b. If two therapies are given in a day, only counts as one day total c. You cannot include evaluation time in minutes d. All of the above A C FH76a-Developed by Polaris Group www.polaris-group.com Page 3 of 99

MDS 3.0 Training Sections G, GG & O 1 SECTION G https://www.youtube.com/watch?v=t-6e5nv4j6k. 2 FH76a-Developed by Polaris Group www.polaris-group.com Page 4 of 99

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G0110 Column 1 Assessment Guidelines Record the actual resident self-performance on each ADL. Self-performance may vary day-to-day, shift-to-shift, within shifts, 24 hours a day. Consider the resident s performance when using adaptive devices. Do not include assistance provided by family or other visitors, private duty, hospice care providers, Student Nursing/aides., nor ambulance personnel. Do include nurses, therapy staff, aides. 5 Section G Functional Status INDEPENDENT: No help or staff oversight (this means no physical help, or cueing or prompting) or Staff help (at any level of support). May have set-up help and still be independent. Independent means staff does not need to be present. If staff is present, it is NOT to assist or cue the resident. For example, you may walk with a resident down the hall, or visit during a meal, but you do not need to be there, as the resident is independent. To code on MDS must be 100% of the time. 6 FH76a-Developed by Polaris Group www.polaris-group.com Page 6 of 99

Section G Functional Status SUPERVISION: Oversight, encouragement, or cueing Supervision does not involve any physical help, with the exception of set-up only. Examples: frequent reminders to reposition in bed, encouragement to ambulate, reminders to use walker when left in the room, encouragement and supervision with use of trapeze, or stand-by assistance. General supervision in dining room is not coded here. Two residents together to be supervised should be coded here. 7 Section G Functional Status LIMITED ASSISTANCE: The resident is highly involved in the activity, he/she received physical assistance in guided maneuvering of the limbs. Include subtasks within the total activity Resident is lifting their leg, lifting their arm, rising up, and the staff only needs to touch them to guide limb or body. Once the staff is lifting the leg, arm, elbow, or holding any part of the body and having to provide resistance or weight-bearing Resident can lift arms, but needs help to get them into the sleeves of the clothes. If the resident is independent in some sub-tasks but staff combs her hair, that is extensive assist. Contact guard assistance during ambulation - resident rebalances self. 8 FH76a-Developed by Polaris Group www.polaris-group.com Page 7 of 99

Section G Functional Status EXTENSIVE ASSISTANCE: Weight-bearing support Include subtasks within the total activity Who is supporting the weight of the hand, leg, body, etc.? Weight-bearing support includes lifting arms, holding elbow and lifting up when rising, holding hands and resident is leaning into staff hands relying on them for support. 9 Section G Functional Status TOTAL DEPENDENCE: Full Staff performance of the activity 100% of the time during the 7-day look-back period. 100% tube feedings for eating Full lift or Hoyer lift and the resident does not assist or participate in any way Total assist in dining, no finger foods or holding a glass Incontinent with all pericare provided by staff Activity only occurred 2 times Activity did not occur - resident did not ambulate or transfer during look-back period or non-facility staff provided care 100% of the time. 10 FH76a-Developed by Polaris Group www.polaris-group.com Page 8 of 99

Section G Functional Status ADL SUPPORT: Code most support during look-back period Code 0, no setup or physical help from staff. Code 1, setup help only: if resident is provided with materials or devices necessary to perform the ADL independently. This can include giving or holding out an item that the resident takes from the caregiver. Code 2, one person physical assist: if the resident was assisted by one staff person. Code 3, two+ person physical assist: if the resident was assisted by two or more staff persons. Code 8, ADL activity itself did not occur during the entire period: if, over the 7-day look-back period, the ADL activity did not occur or non-facility staff provided 100% of care 11 Section G Functional Status SET-UP HELP ONLY: The resident is provided with materials or devices necessary to perform ADLs independently Bed Mobility - putting side rail up or down Transfer - giving the resident a transfer board or locking/unlocking the wheels on a wheelchair for safe transfer Handing the resident a walker or cane so resident can walk Eating - cutting meat/opening containers at meals; giving one food category at a time Toileting - Handing a bedpan or placing articles for changing ostomy appliance within reach Dressing - Retrieving clothes from closet, lying out/handing 12 FH76a-Developed by Polaris Group www.polaris-group.com Page 9 of 99

RULE of THREE Instructions for the Rule of Three: If activity only occurred 2 times, code a 7 for self performance Three times at any one given level, code that level. Three times at multiple levels, code the most dependent. Example, three times extensive assistance (3) and three times limited assistance (2), code extensive assistance (3). Exceptions are as follows: Total dependence (4) activity must require full assist every time, and Activity did not occur (8) activity must not have occurred at all. 13 RULE of THREE Occurs at various levels, but not three times at any given level, apply the following: When there is a combination of full staff performance and extensive assistance, code extensive assistance (3). When there is a combination of full staff performance, weight-bearing assistance and/or non-weight-bearing assistance, code limited assistance (2). If none of the above are met, code supervision 14 FH76a-Developed by Polaris Group www.polaris-group.com Page 10 of 99

ADL Self-Performance Algorithm Use the ADL Self-Performance Algorithm to facilitate accurate coding. Provides a step-by-step guide: Determine how to code G0110 Column 1 Self- Performance for each ADL Use the Rule of 3 Start at the top of the algorithm Work down until the coding option in the algorithm matches the ADL assessment. 15 Code 8 Activity Did Not Occur Determine if the ADL occurred at least one time. Code 8 if the resident or staff did not perform the ADL at all during the look-back period and/or non-facility staff provided care 100% of the time 16 FH76a-Developed by Polaris Group www.polaris-group.com Page 11 of 99

Code 7 Activity Occurred Only Once or Twice Determine if ADL occurred three or more times during the look-back period. Code 7 if ADL occurred only once or twice. 17 Code 0 Independent ADL occurred at least three times during the look-back period. Code 0 if the resident did not need ANY assistance or oversight to complete the ADL. 18 FH76a-Developed by Polaris Group www.polaris-group.com Page 12 of 99

Code 4 Total Dependence ADL occurred at least three times during the look-back period. Code 4 if the resident is unwilling or unable to perform any part of the ADL for the entire look-back period. 19 Section G: Activities of Daily Living ADL occurred at least three times during the look-back period. Code 3 if full staff performance was required at least three times but not every time. Code 3 Extensive Assistance Did resident require full staff performance at least 3 times, but not every time, or weight bearing assistance 3 or more times? 20 FH76a-Developed by Polaris Group www.polaris-group.com Page 13 of 99

Code 3 Extensive Assistance ADL occurred at least three times during the look-back period. Code 3 if a combination of full staff performance and weight-bearing assistance was required three or more times. NOTE Asterisk 21 Code 2 Limited Assistance ADL occurred at least three times during the lookback period. Code 2 if the resident required non-weight bearing assistance three or more times. 22 FH76a-Developed by Polaris Group www.polaris-group.com Page 14 of 99

Code 2 Limited Assistance ADL occurred at least three times during the look-back period. Code 2 if resident required a combination of full staff performance/weight-bearing assistance and nonweight-bearing assistance three or more times. NOTE - Asterisk 23 Code 1 Supervision ADL occurred at least three times during the look-back period. Code 1 if resident required oversight, encouragement, or cueing 3 or more times. No 24 FH76a-Developed by Polaris Group www.polaris-group.com Page 15 of 99

Rule 1 Activity Occurs 3 times at any level Rule 2 When occurs 3 or more times at multiple levels; code most dependent 25 Rule of 3 26 FH76a-Developed by Polaris Group www.polaris-group.com Page 16 of 99

Rule of 3 #1- Four episodes of supervision, three episodes weight bearing support - code Extensive #2 Twice Weight bearing support, one fully dependent code Extensive #3 Four supervision, two limited, two weight bearing code Supervision #4 Two limited, two weight bearing code Limited Assist #5 One limited, one weight bearing, one full code Limited 27 Rule of 3 #6 What to code if Supervision was provided 3 or more times? And physical assistance was provided 3 or more times but at different Levels? Code Supervision since met 3 or more rule. 28 FH76a-Developed by Polaris Group www.polaris-group.com Page 17 of 99

Section G Functional Status BED MOBILITY: RUG How the resident moves to and from a lying position, turns side to side, and positions their body while in bed, in a recliner, or other type of furniture the resident sleeps in, rather than a bed. Subtasks: Turning side to side Pulling/pushing up in bed Sitting up and swinging legs to side of bed Laying down, swinging legs onto bed The above, in a recliner/chair if that is where resident sleeps 29 Section G Functional Status BED MOBILITY: RUG A resident always requires one aide to lift up (weight bear) resident with arm behind back to sit up in bed, with another arm under legs swinging over the side as sit up, the resident is also pushing with arms to help. Code a 3 for Ext Asst. for selfperformance and a 2 for one person physical assistance if occurs three or more times. Resident turns self over in bed independently, but in mornings, if bed is elevated, the resident is unable to push self up with feet, one aide has to help pull resident up providing weight bearing support. Code a 3 for Ext. Asst. for self-performance and 2 for one person physical assistance if occurs three or more times. 30 FH76a-Developed by Polaris Group www.polaris-group.com Page 18 of 99

Section G Functional Status TRANSFER: RUG How the resident moves between surfaces to and from the bed, chair, wheelchair, or to a standing position. Excludes movement to and from the bath or toilet, which is coded elsewhere. Subtasks: Rising from one surface such as pushing off from the bed or chair or wheelchair Pivot or steps to move toward next surface Lowering self onto new surface such as bed or chair or wheelchair Includes transfers performed in room, in hall, therapy room 31 Section G Functional Status TRANSFER: RUG If two aides are required for a Hoyer lift transfer per facility policy, both aides must be providing physical assistance to code as a 3 two person physical support. If one aide is only observing, that is not physical support so second aide is not counted automatically. Resident transferred with aide helping to rise by placing a hand under the resident s elbow and providing resistance to help resident to rise is coded a Ext. - 3 for self-performance and 2 for one person physical support if occurs three or more times. Resident always can rise off bed with stand-by supervision, but needs the aide to support weight under arm to lower safely into a chair. This is extensive assist, code a 3 in self-performance. 32 FH76a-Developed by Polaris Group www.polaris-group.com Page 19 of 99

Section G Functional Status EATING: RUG - How the resident eats or drinks, regardless of skill. Includes the intake of nourishment by other means such as tube feeding or parenteral nutrition, and/or IV fluids. Even residents that receive tube feeding 100% for nutrition are eating. 33 Section G Functional Status Eating Subtasks: Lifting hand up to feed self Lifting hand up to feed self with utensil Lifting cup to mouth General supervision in dining room is not coded as supervision on MDS Applies to eating or drinking in room, up in chair, at activities, or in bed at night Does not apply to fluids and food provided during medication pass 34 FH76a-Developed by Polaris Group www.polaris-group.com Page 20 of 99

Section G Functional Status EATING: RUG Does include fluids offered during care in room. Resident holds glass, but needs help to guide to mouth, providing limited assist. Resident can feed self with finger food, but needs full staff support with glass/fluids. This would be coded a Ext. - 3 for self-performance. Resident is being weaned from tube feeding, and resident can feed self orally, but the nurse administers the tube feeding. Since the resident is not fully dependent, this would be coded a Ext. - 3 in self-performance. 35 Section G Functional Status TOILET USE: RUG - How wipes themselves, changes pad, manages ostomy/catheter, adjusts clothes. Includes transferring on/off toilet, commode, bedpan, and use of urinal. Subtasks: Consider both bowel and bladder episodes Pulling pants or underwear down and up Sitting on toilet or commode or bed pan or propping/holding urinal Handing resident toilet paper or pads Cleaning/wiping/cleansing peri-area after voiding Getting off toilet, commode, bedpan or urinal 36 FH76a-Developed by Polaris Group www.polaris-group.com Page 21 of 99

Section G Functional Status TOILET USE: RUG Male resident is independent in use of urinal, but requires limited assist for placement on a bedpan or cleaning after a BM, code as a 2 in self-performance - limited assist with a 2 for one person support. Resident is able to put self on and off bedpan at night, but during the day, requires weight bearing support to sit on toilet. This would be a Ext. - 3 self-performance. 37 ADL Coding non-rug items WALK IN ROOM: How the resident walks between locations in his/her room. Subtasks: Resident must walk IN ROOM to code this otherwise coded an 8 for did not occur. Includes walking to bathroom, closet or around room. Does not include rising to a standing position, that is transfer. 38 FH76a-Developed by Polaris Group www.polaris-group.com Page 22 of 99

ADL Coding non-rug items WALK IN ROOM: Subtasks: It does not matter which staff member is involved, whether nursing or therapy, it is the issue of walking in his/her room. Resident may be in wheelchair most of the time in the room; however ambulating to the toilet is an example of walking in room. Walking across the room to bed is another example. If just a transfer occurs then it is not coded as walking. Rising is not included in walking. 39 ADL Coding non-rug items WALK IN ROOM: During day, resident walks with supervision and set-up in room. During the night, the resident requires extensive assist of one aide to ambulate to bathroom 3 or more times. Code a 3 self-performance and 2 for one person physical support. 40 FH76a-Developed by Polaris Group www.polaris-group.com Page 23 of 99

ADL Coding non-rug items WALK IN CORRIDOR: How the resident walks in corridor on unit. This is the immediate area outside of his/her room. Once the resident is walking out the door of their room, they are walking in the corridor. This ADL only addresses the resident s ability to walk short distances outside their room in the adjacent corridor. A resident may be able to walk short distances on their unit but NOT walk further distances. This item evaluates ability to walk shorter distances outside the resident s room. 41 ADL Coding non-rug items WALK IN CORRIDOR: Subtasks: Resident must walk IN CORRIDOR ON UNIT to code this otherwise coded an 8 for did not occur. Corridor is adjacent to the room. Does not include resident who walks only in a therapy room. Does include resident walking in corridor on unit even if walked by therapy. 42 FH76a-Developed by Polaris Group www.polaris-group.com Page 24 of 99

ADL Coding non-rug items WALK IN CORRIDOR: Subtasks: Could include walking to dining room if dining room is on unit. Same for activities. Includes walking up and down hall. If a one story building, the unit is the area around resident s room. This coding does not include the transfer to rise, but the walking/ambulation skill. 43 ADL Coding non-rug items WALK IN CORRIDOR: Resident may never walk in corridor, code as an 8 for self-performance and staff support. May be in wheelchair most of the time but staff may provide extensive support of one person to walk to lunch in dining room every day. This would be a 3 in self-performance. 44 FH76a-Developed by Polaris Group www.polaris-group.com Page 25 of 99

ADL Coding non-rug items LOCOMOTION ON UNIT: How the resident moves between locations in his/her room and adjacent corridor on the same floor. If the resident is in a wheelchair, locomotion is defined as self-sufficiency once in a chair. Subtasks: Modes of locomotion include cane, walker, crutch, hand-propelled or motorized wheelchair, other person pushing resident, even if resident ambulates at times. 45 ADL Coding non-rug items LOCOMOTION ON UNIT: Subtasks: Moving a resident while still in a bed by rolling up the hall counts as locomotion. Once the resident is out of his/her room, there is locomotion on the adjacent corridor/unit. Consider what the resident s self-performance is in using a wheelchair or electric wheelchair once setup. Does not include the transfer. 46 FH76a-Developed by Polaris Group www.polaris-group.com Page 26 of 99

ADL Coding non-rug items LOCOMOTION ON UNIT: Resident is always in Geri-chair and pushed in hall at all times. Self-performance is dependent. Resident can move around in wheelchair on unit but gets tired and 3 times or more in 7 days and is pushed back to room to go to bed to take a nap. Selfperformance is a 3. 47 ADL Coding non-rug items LOCOMOTION OFF UNIT: How the resident moves to and returns from off unit locations (e.g. areas set aside for dining, activities, therapy etc.). If the facility is one floor, locomotion off unit is defined as how the resident moves to and from distant areas on the floor. If in wheelchair, locomotion is defined as self-sufficiency once in chair. 48 FH76a-Developed by Polaris Group www.polaris-group.com Page 27 of 99

ADL Coding non-rug items LOCOMOTION OFF UNIT: Subtasks: Modes of locomotion include cane, walker, crutch, handpropelled or motorized wheelchair, other person pushing resident, even if resident ambulates at times. The issue is distance from room if facility is on one floor. It would be unusual for the resident to be less dependent off the unit than on unit. Even if receiving therapy. This question is how the resident moves on and off the unit going to therapy room not how the resident performs IN therapy room. 49 ADL Coding non-rug items LOCOMOTION OFF UNIT: Resident is always in geri-chair and pushed in hall to any location in the facility. Self-performance is dependent. Resident can move around in wheelchair and leave unit for an activity but is tired and needs to be pushed coming back, if occurs 3 or more times, Self-performance is a 3 with a 2 for one person support. 50 FH76a-Developed by Polaris Group www.polaris-group.com Page 28 of 99

ADL Coding non-rug items DRESSING: How the resident puts on, fastens, and takes off all items of clothing, including donning/removing a prosthesis. Dressing includes street clothes as well as putting on and changing pajamas and housedresses. Subtasks: Putting arms in sleeves of shirt/blouse/sweater/coat Putting on/off bra or other underwear Buttoning/unbuttoning shirt 51 ADL Coding non-rug items DRESSING: Subtasks: Changing sweater Putting legs in/out of pants Zipping or buttoning pants Putting on/taking off socks and shoes Includes putting on/taking off TED-type socks Changing pajamas or house dress 52 FH76a-Developed by Polaris Group www.polaris-group.com Page 29 of 99

ADL Coding non-rug items DRESSING: Resident needs only limited support in ALL subtasks, except on days when he wears a sweater. The aide must lift and hold arm to get sweater on and off. On those days, resident was 3 for self-performance. Each time weight bearing support is provided for any subtask extensive assist is provided. Extensive assistance is only needed 3 or more times during the observation period to code as a 3 for self-performance. 53 ADL Coding non-rug items DRESSING: Resident only needs set-up, but aide must lift legs to put on socks and shoes. This is weight bearing support if occurs 3 or more times. Resident requires only limited assist to dress upper torso in AM, but at night the aides have to lift and hold up arms to undress. This resident is a 3 for self-performance. 54 FH76a-Developed by Polaris Group www.polaris-group.com Page 30 of 99

ADL Coding non-rug items PERSONAL HYGIENE: How the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, and washing/drying face, hands. Exclude from this personal hygiene in baths/showers, which are covered under bathing. Subtasks: Set-up includes setting up equipment and/or washbasin. Lifting hands to wash face Brush teeth 55 ADL Coding non-rug items PERSONAL HYGIENE: Subtasks: Male face shaving Shaving of female as preferred Comb hair - Put on make-up If resident can hold a shaver or hairbrush but is unable to lift arm to comb hair or shave, or staff shaves or combs hair, code as extensive assist since the staff s action replaces a weight-bearing activity. This does NOT include a full sponge bath 56 FH76a-Developed by Polaris Group www.polaris-group.com Page 31 of 99

ADL Coding non-rug items PERSONAL HYGIENE: Resident requires cueing and encouragement to wash and shave. After two days, staff shaves the resident. Staff shaves the resident 4 times in a week. This would be coded as a 3 self-performance with one person physical assist. Resident is independent in all grooming but staff needs to comb hair and put in a ponytail. This is a 3 in selfperformance. Resident needs task segmentation and handed one item at a time with encouragement. This is supervision only. 57 Section G Functional Status 58 FH76a-Developed by Polaris Group www.polaris-group.com Page 32 of 99

Section G Functional Status G0120 Bathing A. Self Performance; code most dependent 0. Independent 1. Supervision oversight only 2. Physical help limited to transfer only 3. Physical help in part of bathing activity 4. Total Dependence 8. Activity did not occur per definition Support provided Same as for ADL support coding 59 Section G Functional Status 60 FH76a-Developed by Polaris Group www.polaris-group.com Page 33 of 99

Section G Functional Status G0300 Balance during transitions Coding 0. Steady at all times 1. Not steady, but able to stabilize without human assistance 2. Not steady, only able to stabilize with human assistance 8. Activity did not occur A. Moving from seated to standing B. Walking, with assistive device if used C. Turning around and facing the opposite direction while walking D. Moving on/off toilet E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) 61 G0300: Observation Observe the resident and review record and staff: Transition from sitting to standing Walking (with assistive device if used) Turning Transfer on and off toilet Transfer from wheelchair to bed and bed to wheelchair 62 FH76a-Developed by Polaris Group www.polaris-group.com Page 34 of 99

G0300: Formal Assessment Conduct a formal assessment of the resident. RAI outlines steps. Explain what the task is and what is being observed. Start with resident sitting up on the edge of bed, in a chair, or in a wheelchair. Ask resident to stand up and stay still for 3-5 seconds. Ask resident to walk approximately 15 feet using any usual assistive device. Ask resident to turn around. 63 G0300: Conduct the Assessment Ask resident to: Walk or wheel from a starting point in the room into the bathroom. Prepare for toileting as normal. Sit on the toilet. Ask any resident who uses a wheelchair for mobility to transfer from a seated position in the wheelchair to a seated position on the bed. 64 FH76a-Developed by Polaris Group www.polaris-group.com Page 35 of 99

65 G0300 Practice #1 A resident with Parkinson s Disease ambulates with a walker. His posture is stooped, and he walks slowly with a shortstepped shuffling gait. On some occasions, his gait speeds up, and it appears he has difficulty slowing down. He has to steady himself using a handrail or a piece of furniture in addition to his walker on multiple occasions during the look-back period. 66 FH76a-Developed by Polaris Group www.polaris-group.com Page 36 of 99

How should G0300B be coded? A. Code 0. Steady at all times. B. Code 1. Not steady, but able to stabilize without staff assistance. C. Code 2. Not steady, only able to stabilize with staff assistance. D. Code 8. Activity did not occur. 67 G0300 Practice #1 Coding Correct code is 1. Not steady but able to stabilize without staff assistance. Resident has an unsteady gait but can stabilize himself using an object such as a handrail or piece of furniture. 68 FH76a-Developed by Polaris Group www.polaris-group.com Page 37 of 99

G0300 Practice #2 A resident who needs assistance with transfers to his wheelchair from the bed. He is observed to stand halfway up and then sit back down on the bed. On a second attempt, a Nursing Assistant helps him stand up straight, pivot, and sit down in his wheelchair. 69 How should G0300E be coded? A. Code 0. Steady at all times. B. Code 1. Not steady, but able to stabilize without staff assistance. C. Code 2. Not steady, only able to stabilize with staff assistance. D. Code 8. Activity did not occur. 70 FH76a-Developed by Polaris Group www.polaris-group.com Page 38 of 99

G0300 Practice #2 Coding The correct code is 2. Not steady, only able to stabilize with staff assistance. The resident was unsteady when transferring from bed to wheelchair and required staff assistance to make a steady transfer. 71 Section G Functional Status 72 FH76a-Developed by Polaris Group www.polaris-group.com Page 39 of 99

Section G Functional Status G0400 Functional Limitation in Range of Motion which interferes with daily functioning/adl Coding 0. No impairment 1. Impairment on one side 2. Impairment on both sides A. Upper extremity B. Lower extremity Perform assessment or review ROM Assessment Tool/Admission/Quarterly Forms 73 Assessment of Functional ROM Observation Formal Assessment 74 FH76a-Developed by Polaris Group www.polaris-group.com Page 40 of 99

Functional ROM: Observation Upper Extremity includes shoulder, elbow, wrist, and fingers Observe the resident donning or removing a shirt over the head. If assessing upper extremity ROM by observing the resident, making a fist mimics useful actions for grasping and letting go of utensils. When an individual reaches both hands to the back of the head, this mimics the action needed to comb hair. 75 Functional ROM: Observation Lower Extremity - includes hip, knee, ankle, and foot; From RAI If assessing lower extremity ROM by observing the resident, the flexion and extension of the foot mimics the motion on the pedals of a bicycle. Extension might also be needed to don a shoe. If assessing bending at the knee, the motion would be similar to lifting of the leg when donning lower body clothing. 76 FH76a-Developed by Polaris Group www.polaris-group.com Page 41 of 99

Functional ROM: Formal Test Ask the resident to follow your verbal instructions for each movement. Demonstrate each movement (e.g., ask the resident to do what you are doing). Actively assist the resident with the movements by supporting his or her extremity and guiding it through the joint ROM. Observe resident; only code if limitation interferes with ADLs. If resident requires Passive ROM then there is a limitation. 77 Functional ROM: Formal Test Lower Extremity - includes hip, knee, ankle, and foot; From RAI While resident is lying supine in a flat bed, instruct the resident to flex (pull toes up towards head) and extend (push toes down away from head) each foot. Then ask the resident to lift his or her leg one at a time, bending it at the knee to a right angle (90 degrees) Then ask the resident to slowly lower his or her leg and extend it flat on the mattress. 78 FH76a-Developed by Polaris Group www.polaris-group.com Page 42 of 99

Functional ROM: Formal Test Upper Extremity includes shoulder, elbow, wrist, and fingers For each hand, instruct the resident to make a fist and then open the hand. With resident seated in a chair, instruct him or her to reach with both hands and touch palms to back of head. Then ask resident to touch each shoulder with the opposite hand. 79 Section G Functional Status 80 FH76a-Developed by Polaris Group www.polaris-group.com Page 43 of 99

Section G Functional Status G0600 Mobility Devices A. Cane/crutch B. Walker - any type and includes pushing wheelchair C. W/C any type; moving about in any way D. Limb Prosthesis replacing missing extremity Z. None or no locomotion during look-back period 81 Section G Functional Status 82 FH76a-Developed by Polaris Group www.polaris-group.com Page 44 of 99

Section G Functional Status G0900 Admission (A0310A=01) only, Rehab Potential Resident thinks capable of increased independence? No, Yes, Unable to determine (resident cannot indicate) Direct care staff believe capable increased independence? No, Yes 83 Therapy s Role in ADL Scoring Consider therapy documentation if needed to find a 3 rd Extensive. ADLs are clearly part of a therapy plan and the levels of assistance can be a component of the discussions with the MDS Coordinator following the Rule of Three. Provide feedback regarding the late loss ADLs as noted during therapy sessions in the last 7 day; consideration will always be towards scoring the most dependent status. Therapy documentation will provide continued support for late loss ADLs through daily and weekly notes. 84 FH76a-Developed by Polaris Group www.polaris-group.com Page 45 of 99

Nursing (MDS Definitions) Crosswalk to Therapy Independent Independent No help or staff oversight Supervised Supervised Oversight, encouragement, or cueing Stand-by assist without provided (no hands on) touching Limited Assistance Contact Guard Physical help in guided maneuvering of limbs or other non weight-bearing assistance Extensive Assistance Weight bearing support provided by staff Total Dependence Full Staff Performance of the activity Stand-by assist with touching but no weight-bearing Minimum Assistance (some weight bearing support) Moderate Assistance Maximum Assistance Dependent or NT Not tested for Dependence 85 ADL Scores 4 th Quarter 2016 3 rd Quarter 2016 2 nd Quarter 2016 1 st Quarter 2016 4 th Quarter 2015 ADL Level % % % % % X 0.79 0.88 1.13 1.04 0.93 L 0.69 0.65 0.77 0.78 0.65 C 33.59 32.99 33.79 33.78 33.47 B 39.16 39.98 39.28 39.63 39.21 A 25.77 25.50 25.03 24.78 25.74 * Source Polaris Group KIT Database FH76a-Developed by Polaris Group www.polaris-group.com Page 46 of 99

ADL Scores Identifies MDS Coordinator training needs Identifies documentation deficiencies Revenue between an A and a C can be over $100 a day 87 ADL Data Gathering ADL data gathering - score of 6 to achieve B 3 out of 4 ADLs need to be Extensive Assist Data gathering By Shift limits total events May have only two shifts with Extensive for an ADL Interview staff; likely ext. assist was provided 3 or more times during look back chart to true number of times. Collect ADL Data gathering to by event If transfer 3 times on one shift, capture all 3 times. 88 FH76a-Developed by Polaris Group www.polaris-group.com Page 47 of 99

Documentation for Section G Have formal data gathering methods for Medicare residents Have formal data gathering systems for OBRA Initial, Quarterly, and Annual Assessments as well as Significant Clinical Change Assessments, especially needed if a Case Mix State. Ideas to limit copycat charting: Have data sheets separated for each shift, consider having worksheets turned in at the end of the shift. Nurse then transfers to flow sheet like vital signs. May consider self-performance and support in therapy when coding Section G. 89 Documentation for Section G If the MDS Nurse is going to code ADLs on the MDS in conflict with medical record documentation, then a summary note of findings should be written in the clinical record. Implement MDS ADL training for aides, nurses, and MDS Nurse in orientation with competency test. Implement a MDS cheat sheet for new hires and temporary agency staff for quick reference. Post MDS/ADLs related posters and signs to serve as ongoing fun reminders. 90 FH76a-Developed by Polaris Group www.polaris-group.com Page 48 of 99

Documentation for Section G Provide inservices every 3 months on MDS and related ADLs. Allow time for aides to document; get rid of any unnecessary documentation. 91 CODING DIRECTIONS GG 92 FH76a-Developed by Polaris Group www.polaris-group.com Page 49 of 99

Admission and Discharge Performance Coding Directions Based on direct observation, resident s self report, family reports, and direct care reports as documented in medical record. Helper must be a facility staff or contracted employee by facility Not Hospice staff, students, or private staff by family If family/private duty gives all care, then code as 07 Resident Refuses or 09 Not Applicable 93 Admission and Discharge Performance Coding Directions May be completed with or without a device Usual performance is not most independent or most dependent; if there is a fluctuation, code to the most usual for that resident. average care Do not code what could do but usual performance Over three days what was most common performance for the resident. CMS focuses on therapy initial evaluation as assessment 94 FH76a-Developed by Polaris Group www.polaris-group.com Page 50 of 99

Admission and Discharge Performance Coding Directions CMS states this is an assessment and should focus on baseline at time of admission or discharge. 95 Admission and Discharge Performance Coding Directions CMS states this is an assessment and should focus on baseline at time of admission or discharge. Discharge best reflection of performance status at discharge. CMS focused on Therapy Discharge note. 96 FH76a-Developed by Polaris Group www.polaris-group.com Page 51 of 99

06 Independent - Similar to coding Independent Section G without set-up help support. 05 Set-up or Clean-up Assistance - Similar to coding Independent in Section G but WITH set-up only support. Could easily apply to oral hygiene, or eating skills. No physical help or cueing needed most of the time. 97 Similar to coding Supervision in Section G Similar to coding limited assist in Section G This is verbal cueing or Contact Guard support. This is clearly non-weight bearing support to provide safety to complete task. Again, usual care, versus most dependent. 98 FH76a-Developed by Polaris Group www.polaris-group.com Page 52 of 99

Weight Bearing Support usually provided 03 More like Minimum Assist used by Rehab Extensive Assist in Section G one person 02 More like Moderate to Maximum Assist by Rehab so more weight bearing support provided Extensive Assist in Section G one person 99 First Step: Determine if weight bearing support is usually provided (does not usually require two staff) Second Step: If yes, then does resident perform less than half the activity/half the effort or more than half of the activity/more than half the effort (tasks with most weight bearing effort) Three subtasks - resident perform two, staff one or visa versa. 100 FH76a-Developed by Polaris Group www.polaris-group.com Page 53 of 99

Dependent code on MDS Section G Usually resident does not participate in activity Even if resident performs some of activity, if it requires two or more staff to assist, code as dependent. 101 07 - Document refusal if applies 09 - Document reason, info indicates not performed prior to current status 88 - Not attempted, Medical Condition supports coding (CMS states expects to see 88 coding) ***Tetraplegic activity of sit to stand not attempted. ***Bedrest uses bedpan Toilet Transfer not attempted 102 FH76a-Developed by Polaris Group www.polaris-group.com Page 54 of 99

07 - Resident refused 09 - Not applicable CMS Training example of resident had G-tube prior to SNF admission, so code 09 for eating. 88 - Not attempted due to Medical Condition or safety CMS Training example of resident with G-tube new with this SNF admission, code 88 for Eating. 103 These codes explain why there is no performance to measure at Admission or Discharge Performance, you should never have to dash performance item. 104 FH76a-Developed by Polaris Group www.polaris-group.com Page 55 of 99

Do Not Dash Performance Items 105 Section G 0 Independent 0 Independent with Set Up help Only 1 Supervision; cueing 2 Limited Assistance nonweight bearing support 3 Extensive Assistance weight bearing support 4 Total Dependence 100% of the time staff provide care 7 Occurred only once or twice 8 Activity did not occur Three or more rule 7 day observation period Crosswalk to Section GG 06 Independent 05 Set up/clean up help only 04 Supervision or touching assistance cueing or contact limited assistance 03 Partial/Moderate assistance less than half of effort 02 Substantial/Maximal assistance more than half of effort 01 Dependent Staff usually do all of activity or usually requires 2 person assistance 07 Resident Refused; 09 Not Applicable 88 Not attempted due to medical condition Usual care/baseline; average care, not most dependent or most independent 3 day observation period 106 FH76a-Developed by Polaris Group www.polaris-group.com Page 56 of 99

107 108 FH76a-Developed by Polaris Group www.polaris-group.com Page 57 of 99

Aligns with Eating in Section G Independent for most of meal, then requires some physical help to finish: Code 03 - Partial/moderate assistance Physical help to eat more than half the meal: Code 02 Substantial/maximal assistance Both of the above provide weight bearing support Encouragement, reminders, handing utensils/cup: Code 04 Supervision/touching Fed entire meal: Code 01- Dependent 109 Subtask of Personal Hygiene in Section G Staff puts toothpaste on toothbrush, then brushes teeth without cueing: Code 05 Set-up or clean-up assistance Starts to brush teeth, but stops and completed by staff; Code 02 Substantial/Maximal Assistance since more than half the activity by staff Brushes gums and starts dentures but staff completes: Code 03 Partial/Moderate Assistance Fully dependent: Code 01 - Dependent Brushes teeth/dentures with set-up but needs cueing to complete: Code 04 - Supervision/Touching assistance 110 FH76a-Developed by Polaris Group www.polaris-group.com Page 58 of 99

Aligns with Toilet Use in Section G minus the transfer itself to toilet/commode; this item is only hygiene tasks. Uses commode, aide only provides steadying assistance while resident wipes self, and pulls up pants: Code 04 - Supervision/touching assistance Staff lifts gown, and pulls down pants, but resident wipes and pulls pants back up: Code 03 - Partial/Moderate assistance Staff wipes and pulls pants down, resident only lifts gown: Code 02 - Substantial/Maximal assistance Staff do all activities: Code 01 - Dependent 111 112 FH76a-Developed by Polaris Group www.polaris-group.com Page 59 of 99

113 Requires assistance from sitting on bed to lying on bed, staff lifts up legs, but resident uses arms to position upper body; weight bearing support for less than half of tasks: Code 03 - Partial/Moderate assistance Staff support trunk when lying down and lifts legs weight bearing support for all tasks: Code 02 - Substantial/Maximal assistance 114 FH76a-Developed by Polaris Group www.polaris-group.com Page 60 of 99

Resident pushes up from bed from lying to sitting; staff only provides steadying support: Limited assistance: Code 04 - Supervision or Touching Assistance Staff provide much of the lifting assistance to get from lying to sitting position, weight bearing support: Code 02 - Substantial/Maximal Assistance Resident rolls to side and pushes self up from lying to sitting with verbal cues: Code 04 - Supervision or Touching Assistance Full staff support: 01 - Dependent 115 Resident transitions from sitting to standing with only contact limited assistance: Code 04 - Supervision or Touching assistance Two person assistance: Code 01 Dependent Staff provide weight bearing support to rise to standing position and balance: Code 02 - Substantial/maximal assistance Staff provide weight bearing support to initially start to rise but resident does most of work: Code 03 - Partial/moderate assistance 116 FH76a-Developed by Polaris Group www.polaris-group.com Page 61 of 99

Transfers safely once wheelchair positioned, with set-up only: Code 05 Set-up or clean-up assistance Pivots and transfers to wheelchair with only contact limited assistance: Code 04 - Supervision or Touching assistance Resident requires weight bearing support but pushes self and moves own feet to pivot: Code 03 - Partial/Moderate assistance 117 Transfer to toilet/commode is subtask of Toilet Use in Section G; ONLY transfer to toilet or commode applies Transfers safely to toilet after putting wheelchair by commode: Code 05 Set-up or clean up assistance Transfers on and off toilet with contact limited assistance for safety: Code 04 - Supervision or Touching assistance Weight bearing assistance on and off toilet or commode; so more than half of effort: Code 02 - Substantial/maximal assistance Staff provides full assist to rise, and resident lowers self with grab bars by toilet: Code 03 - Partial/Moderate assistance 118 FH76a-Developed by Polaris Group www.polaris-group.com Page 62 of 99

Code 2 Yes, if resident is able to walk any distance. Code 1 No, not walking during observation period, but goal to walk is indicated Code 2 Yes, then continue 119 J - Walks around 60 feet with two turns, therapy only provided cueing and contact limited assistance: Code 04 - Supervision or Touching assistance J - Walks around 70 feet with crutches, and staff provides some weight bearing support to trunk: Code 03 - Partial/moderate assistance J Walks 50 feet with two turns, loses balance and requires significant supports: Code 02 - Substantial/Maximal Assistance 120 FH76a-Developed by Polaris Group www.polaris-group.com Page 63 of 99

Coding Clarifications Turn is 90 degree turn Can be in same direction or different directions RAI does not say what to code if can walk but only 10 feet with no turns. Suggest code 88 Activity not attempted due to medical condition or safety concerns 121 K Cannot walk 150 feet due to CHF: Code 88 - Activity not attempted due to medical concerns (but can walk shorter distance) K Walks length of hallway, weight bearing support that prevents from falling, provides more than half the effort: Code 02 - Substantial/maximal assistance K Walks length of hallway, using quad cane, requires some weight bearing support: Code 03 - Partial/moderate assistance 122 FH76a-Developed by Polaris Group www.polaris-group.com Page 64 of 99

Coding Clarification Bottom line: If can walk, but not up to 50 feet with two turns, and/or up to 150 feet - code as 88 Activity Not attempted due to Medical condition or safety. Exception: resident refuses code 07 Resident Refuses, or code 09 Not Applicable if not walking now but you hope they will. 123 Aligns with locomotion on unit and off unit Yes or No does resident use wheelchair or scooter? Turns are 90 degree 124 FH76a-Developed by Polaris Group www.polaris-group.com Page 65 of 99

R - Once in w/c resident propels self in wheel chair 60 feet with two turns with no help: Code 06 Independent R - Staff must make frequent adjustments of hand positions, and resident becomes stuck near walls, but when repositioned, can propel and turn self: Code 03 - Partial/moderate assistance R - Can wheel self only 10 feet, then asks aide to push them: Code 02 - Substantial/maximal assistance 125 S Motorized w/c requires safety reminders, and requires staff assistant to backing up when barriers present: Code 03 - Partial/moderate assistance S Uses motorized scooter around SNF with only cues for safety issues: Code 04 Supervision or touching assistance S Uses w/c around SNF after positioned by bed: Code 05 Set-up only 126 FH76a-Developed by Polaris Group www.polaris-group.com Page 66 of 99

Coding Clarification If resident uses wheelchair but never propels themselves, then for each distance (assuming they are pushed both distances) code 01 Dependent. Once propels self in wheelchair any distance, like their example of 10 feet, then staff complete distance, code 02 Substantial/maximal assistance. If uses any type of motorized scooter, code as motorized. 127 Discharge Goal Coding 5-day MDS Use same 6 point scale Do not use codes 07, 09, or 88 for Discharge Goal Established at time of admission when coding 5-day MDS, based on discussions with resident, family, staff, and professional judgement. Goal is part of overall care plan Only code a Discharge Goal if there is one; OK to leave blank if not pertinent to discharge Only need ONE goal coded across all performance items to meet criteria for QM. 128 FH76a-Developed by Polaris Group www.polaris-group.com Page 67 of 99

Data Gathering RAI states assessment is based on direct observation, resident/family self report, direct care staff reports documented in medical record. Then RAI promotes interviewing aides for subtleties especially related to more than half or less than half of effort for weight bearing. CMS examples focused on using therapy initial evaluation and discharge note as the assessment document. 129 What is Usual Care at Admission? Look at therapy evaluation for admission baseline status. Look at admission nursing note for admission baseline status. Observe and assess resident. Review nurses notes for 3-day observation period. Interview family, resident and staff as needed. Look at ADL type flow sheets. ** if in doubt, code to greater deficit at admission. 130 FH76a-Developed by Polaris Group www.polaris-group.com Page 68 of 99

What is Usual Care at Discharge? Look at therapy progress notes last three days; and therapy discharge summary; may also look at nursing documentation last three days of Part A stay observation period. Discharge performance is status at discharge. Do not dash discharge performance. CMS case study used therapy discharge note as assessment source for usual performance at Discharge. 131 Documentation Review therapy evaluation and documentation for baseline status at admission and discharge status. Document to ADL items as part of skilled note, walking and w/c in detail as part of shift notes during 3-day observation period at start and end of stay. First three days of Part A stay Staff know when NOMNC issued and start 3-day End of Stay observation period 132 FH76a-Developed by Polaris Group www.polaris-group.com Page 69 of 99

Data Gathering How do aides contribute to this assessment Education so understand when interviewed about more or less than half the effort Aide charting is not the primary assessment to support coding. Suggest MDSC and Therapy focus on assessing resident to usual performance versus data gathering focus 133 Who Should Code on MDS? Suggest therapy and MDSC collaborate; review documentation, and decide on code of performance and which items have a discharge goal. Add to daily PPS meeting discussions prior to completion and submission of 5-day MDS. MDSC attests to accuracy. At end of stay, MDSC code end of stay performance based on therapy discharge status note when applies; therapy reviews. 134 FH76a-Developed by Polaris Group www.polaris-group.com Page 70 of 99

SECTION O 135 136 FH76a-Developed by Polaris Group www.polaris-group.com Page 71 of 99

Section O Special Treatments and Procedures O0100 Special Treatments - 14-day look-back period 1. While NOT a resident leave blank if not admitted/readmitted in last 14 days (regardless of discharge tracking designation). Services given day of discharge in the hospital would also be coded here. 2. While a resident performed in last 14 days regardless of location (e.g. offsite for dialysis). Do not code services if provided solely in conjunction with surgical procedure including routine pre/post-op care. May code items performed in part by resident independently or after set-up. 137 Section O Special Treatments and Procedures Cancer Treatments A. Chemotherapy (for cancer tx) RUG any route B. Radiation RUG - any type C. Oxygen therapy RUG continuous/intermittent, Code if used with BiPAP/CPAP; do not code hyperbaric oxygen wound treatments here. May also code if resident places and removes own oxygen mask or cannula. 138 FH76a-Developed by Polaris Group www.polaris-group.com Page 72 of 99

Section O Special Treatments and Procedures Respiratory D. Suctioning trach/nasopharyngeal; may be coded if performed by resident. E. Tracheostomy care RUG May be coded if resident performs own suctioning. F. Ventilator or respirator RUG do not code if used as substitute for BiPAP G. BiPAP/CPAP May also code if resident places and removes own BiPAP/CPAP mask. 139 Section O Special Treatments and Procedures Other H. IV medications RUG I. Transfusions RUG - (exclude if with dialysis/chemo) J. Dialysis any type and location. This item may be coded if the resident performs his/her own dialysis. K. Hospice care licensed by state and/or certified by Medicare L. Respite care M. Isolation or quarantine - RUG Z. None of the above 140 FH76a-Developed by Polaris Group www.polaris-group.com Page 73 of 99

Section O Special Treatments and Procedures IV Medications Any drug or biological administered via IV push, epidural/intrathecal/baclofen pump, or drip through central line or peripheral port. Do not code subcutaneous pumps. Do not include IV meds administered with dialysis or chemo. Dextrose 50% and/or Lactated Ringers given IV are not considered medications, and should not be coded here. Do not code saline or heparin flushes to keep lock patent. Do not code IV fluids without meds here. 141 Strict Isolation Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove use, and additionally may include masks, eye protection, and gowns. 142 FH76a-Developed by Polaris Group www.polaris-group.com Page 74 of 99

Strict Isolation Code for strict isolation only when all four of the following conditions are met: 1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. 2. Precautions are over and above standard precautions. That is transmission-based precautions (contact, droplet, and/or airborne) must be in effect. 143 Strict Isolation Code for strict isolation only when all of the following conditions are met: 3. The resident is in a room alone because of active infection and cannot have a roommate. Cannot cohort even with a resident with similar infection. 4. The resident must remain in his/her room. This requires that services be brought (activities, dining, etc.). 144 FH76a-Developed by Polaris Group www.polaris-group.com Page 75 of 99

Isolation Coding Examples of when the isolation criterion would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. Physician documentation to support diagnosis and isolation. Care plan address IC practices. Care plan is updated as needed and consider SCSA. Train therapy staff as indicated for resident s condition. 145 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guideli nes/isolation2007.pdf 146 FH76a-Developed by Polaris Group www.polaris-group.com Page 76 of 99

Influenza Vaccine 147 O0250 Conduct the Assessment 1. Review the medical record to determine: If the resident received an Influenza vaccination Where the vaccination was administered 2. Ask resident if received Influenza vaccine outside of the facility for the year s Influenza season. 3. Ask a responsible party/legal guardian and/or primary care physician if resident is unable to answer. If unable to determine, then give flu vaccination. Influenza season varies and is set every year by the CDC; so refer to current RAI manual. 148 FH76a-Developed by Polaris Group www.polaris-group.com Page 77 of 99

Section O Special Treatments and Procedures O0250 Influenza vaccine A. Did resident receive in facility? B. Date 0. No 1. Yes C. If not received, state reason: 1. Resident not in this facility 2. Received outside facility 3. Not eligible 4. Offered and declined 5. Not offered 6. Inability to obtain vaccine 9. None of the above 149 Section O Special Treatments and Procedures 150 FH76a-Developed by Polaris Group www.polaris-group.com Page 78 of 99

O0300 Assessment Guidelines Administer the vaccine according to standards of clinical practice if vaccination status cannot be determined. Pneumococcal vaccine is given once in a lifetime, with certain exceptions. All adults 65 years of age or older should get the Pneumococcal vaccine. Some persons should receive the vaccine before age 65. 151 Section O Special Treatments and Procedures O0300 Pneumococcal Vaccine A. Pneumococcal up to date? If no, indicate reason B. If not received, state reason: 1. Not eligible (medical contraindication) 2. Offered and declined 3. Not offered CMS to determine how to code if offered, accepted but vaccine not available. 152 FH76a-Developed by Polaris Group www.polaris-group.com Page 79 of 99

153 Section O Special Treatments and Procedures To be coded on MDS; therapy services would be skilled services Would not code therapy provided upon request of resident that is not skilled or maintenance Mode of each therapy received Residents time in therapy (which includes respiratory therapy) Number of minutes and number of days Include only therapy provided once living/being cared for in facility or readmitted 154 FH76a-Developed by Polaris Group www.polaris-group.com Page 80 of 99

Section O Special Treatments and Procedures O0400 Therapy 1. Individual Minutes 2. Concurrent Minutes 3. Group Minutes Grouper will use sum of individual, concurrent, and group minutes to determine total RUG minutes 4. Total number of days at least 15 minutes or more considering all types of minutes. Consider ALL concurrent minutes 155 Section O Special Treatments and Procedures Counting minutes Count only minutes since admission Do not round minutes Do not count evaluation minutes or documentation minutes Re-evaluation minutes count Therapy Assistants can count per state oversight Family education can count if resident is present and documented 156 FH76a-Developed by Polaris Group www.polaris-group.com Page 81 of 99

Section O Special Treatments and Procedures Counting minutes Therapy Aides cannot provide skilled services beyond set up minutes Setting up minutes do count Transport minutes do not count Co-treatment full resident minutes can be coded for each discipline as individual minutes Therapy Students can count within line of sight 157 Section O Special Treatments and Procedures Count/Code Resident Time in Therapy for each type of activity Individual Minutes Medicare Part A All Individual resident therapy minutes count - one therapist or assistant to one resident Co-treatments code as individual minutes 158 FH76a-Developed by Polaris Group www.polaris-group.com Page 82 of 99

Section O Special Treatments and Procedures Concurrent Therapy Medicare Part A All concurrent minutes count toward daily minutes Two residents treated at same time by one therapist/assistant Each resident is performing different activities Regardless of payer source, if one resident is Part A, it applies to Part A resident in terms of coding on MDS. Both residents must be within line of sight of therapist/assistant Concurrent minutes do not need to be in clarification order 159 Section O Special Treatments and Procedures Concurrent Minutes Grouper will allocate only half of the concurrent minutes toward a therapy RUG category Resident concurrent minutes are 30; allocated minutes used for RUG is 15 minutes - divided in half by grouper Resident was in therapy for 46 minutes; 46 minutes are coded on MDS in Concurrent Therapy. The Grouper will only count 23 minutes toward RUG Grouper rounds mathematically up or down. 33 min = 16.5. 17 minutes used for grouper 160 FH76a-Developed by Polaris Group www.polaris-group.com Page 83 of 99

Section O Special Treatments and Procedures Group Minutes Medicare Part A Group of 2-4 perform similar activities with one treating therapist or assistant Group minutes should be in clarification order 161 Section O Special Treatments and Procedures Group Minutes Medicare Part A Group of 4 perform similar activities with one treating therapist or assistant. Only 25% of Resident minutes contribute to RUG. Capped at 25% of total reimbursable minutes for each discipline. Group minutes should be in clarification order. 162 FH76a-Developed by Polaris Group www.polaris-group.com Page 84 of 99

Impact: Group Minutes Groups must be planned for 4 residents. 30 minutes with 4 residents; is 30 minutes on each resident s MDS. However, only 7.5 (8) minutes is considered RTM by grouper to calculate RUG. Only 8 minutes is used to calculate the 25% cap. If one or two residents miss planned 4 person group therapy, SNF may still code as group minutes on MDS, and allocation still applies. 163 Co-treatment Item Co-treatment minutes are coded as individual minutes. If there is one discipline with co-treatment minutes, there would have to be a second with co-treatment minutes. These minutes would match. No indication this item will impact RUG calculations. 164 FH76a-Developed by Polaris Group www.polaris-group.com Page 85 of 99

Co-treatment Coding Example PT delivered 221 individual minutes over the last 7 days. Of those individual minutes, 101 were cotreatment minutes with OT. Code 221 Individual Minutes Code 101 Co-treatment Minutes OT delivered 101 individual minutes over last 7 days. Of those individual minutes, all were co-treatment minutes with PT. Code 101 Individual Minutes Code 101 Co-treatment Minutes 165 Section O Special Treatments and Procedures 5. Therapy Start date first day therapy started Start of Therapy Rehab RUG billed first day with therapy Day Evaluation done even if treatment not provided 6. Therapy End date - End of Therapy This is the last day of therapy date. (CMS ongoing clarifications) A non-therapy/medical RUG is billed the first day without therapy Carry Start and End dates over to subsequent MDS 166 FH76a-Developed by Polaris Group www.polaris-group.com Page 86 of 99

Therapy End Date Therapy End Date Record the date the most recent therapy regimen (since the most recent entry) ended. This is the last date the resident received skilled therapy treatment. Enter dashes if therapy is ongoing. Scenario One: End of Therapy date is planned. Once the last therapy is discontinued/end date is last day received; and resident stays on Part A for another skilled service; an End of Therapy MDS must be completed to bill Medical RUG. Scenario Two: Resident is on Part A, still on case load, when unexpectedly discharged. 167 168 FH76a-Developed by Polaris Group www.polaris-group.com Page 87 of 99

Section O Special Treatments and Procedures D. Respiratory Therapy 1. Total minutes 2. Days RUG E. Psychological Therapy; any licensed MH professional as allowed by your State; does not include Psychiatric Technician. Cannot also code as a physician visit. 1. Total minutes 2. Days F. Recreational Therapy 1. Total minutes 2. Days 169 Section O - Respiratory Therapy For purposes of the MDS, providers should record services for respiratory, psychological, and recreational therapies (Item O0400D, E, and F) when the following criteria are met: the physician orders the therapy; the physician s order includes a statement of frequency, duration, and scope of treatment; 170 FH76a-Developed by Polaris Group www.polaris-group.com Page 88 of 99

Section O - Respiratory Therapy services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by qualified personnel; the services are required and provided by qualified personnel; the services must be reasonable and necessary for treatment of the resident s condition. 171 Section O - Respiratory Therapy Respiratory Therapy: Appendix A: Services 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, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. Does not include hand-held medication dispensers. 172 FH76a-Developed by Polaris Group www.polaris-group.com Page 89 of 99

Section O - Respiratory Therapy Respiratory Nurse: Appendix A A nurse who received specific training on the administration of respiratory treatments and procedures when permitted by the State Nurse Practice Act. This training may have been provided at a hospital or nursing facility as part of work experience or as part of an academic program. Nurses do not necessarily learn these procedures as part of their formal nurse training programs. 173 Section O Special Treatments and Procedures Recreational Therapist Professionals who hold a national certification in therapeutic recreation and the credential of Certified Therapeutic Recreation Specialist. Psychological Therapy Provided only by any licensed mental health professional, such as a psychiatrist, psychologist, psychiatric nurse, or psychiatric social worker. (per state specific licensure). Does not include Psychiatric Technician. 174 FH76a-Developed by Polaris Group www.polaris-group.com Page 90 of 99

Distinct Calendar Days ARD would determine past 7 days. 175 Distinct Calendar Days Daily Skilled Service: 5 distinct days a week for therapy to be considered skilled. Not Daily: PT M, W, F, and OT M, W Only 3 Distinct Calendar days Must be 5 distinct days, for example: PT is scheduled 3 days each week (M, W, F) OT is scheduled 2 other days each week (T, Th) 176 FH76a-Developed by Polaris Group www.polaris-group.com Page 91 of 99

Distinct Calendar Days Daily Skilled Service: Requires a legitimate medical need for scheduling a therapy session each day or the daily basis requirement for skilled coverage. The basic issue here is not whether the services are needed, but when they are needed. No indication yet what this means to Short Stay qualifiers. 177 Distinct Calendar Days OT Monday thru Friday and PT is Tuesday thru Saturday 6 distinct calendar days therapy were provided. 178 FH76a-Developed by Polaris Group www.polaris-group.com Page 92 of 99

Section O Special Treatments & Procedures Only complete if MDS is an EOT or SOT/EOT combo: When the Resumption rules apply Resume within 5 days of end of therapy Resumes at same level for each discipline 179 Section O Special Treatments and Procedures 180 FH76a-Developed by Polaris Group www.polaris-group.com Page 93 of 99

Section O Special Treatments and Procedures O0500 Nursing Rehab/ Restorative - # of days restorative provided at least 15 minutes over last 7 days RUG Technique Training and Practice A. ROM Passive D. Bed mobility B. ROM active/active assist E. Transfer C. Splint/brace teaching or F. Walking scheduled program G. Dressing and Grooming H. Eating and Swallowing I. Amputation/prosthesis J. Communication 181 Section O Special Treatments and Procedures Restorative must be 6 days a week to impact RUG Can be spread out over the course of the day Oversight by nursing Measurable goals and reassessment Aides trained to skills needed In a state with RUGs for Medicaid reimbursement Continue to prove medical necessity and delivery 182 FH76a-Developed by Polaris Group www.polaris-group.com Page 94 of 99

Section O Special Treatments and Procedures 183 Section O Special Treatments and Procedures O0600 - Physician Examinations - MD, NP, PA, or CNS in collaboration with MD) Over last 14 days, how many days did physician examine resident Do not count exams at hospital prior to admission or ER/observation stay Off-site during stay counts Telehealth visits count if excepted by Medicare 184 FH76a-Developed by Polaris Group www.polaris-group.com Page 95 of 99