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Top 5 Discrepant MDS Sections 1.Section P - Special Treatments and Procedures 2. Section I - Disease Diagnosis 3. Section O - Medications 4. Section J – Health Conditions 5. Section G – Physical Functioning and Structural Problems

Top 5 Discrepant Section G items 1.G1b(A) - Transfers/Self-Performance 2.G1a(A) - Bed Mobility/Self -Performance 3.G1i(A) – Toilet Use/Self-Performance 4.G1d(A) –Walk in Room/Self-Performance 5.G1a(B) – Bed Mobility/Support Provided

Section G 1 Physical Functioning and Structural Problems

G1(A) - ADL Self-Performance Codes 0. Independent 1. Supervision 2. Limited Assistance 3. Extensive Assistance 4. Total Dependence 8. Activity Did Not Occur During the Entire 7 Day Period

Staff Support G1 (B) ADL Support Provided Codes 0. No Setup or Physical Help from Staff 1. Setup Help Only 2. One Person Physical Assist 3. Two+ Persons Physical Assist 8. ADL Activity Itself Did Not Occur During the Entire 7 Days

Revised Long-Term Care Resident Assessment Instrument User’s Manual, Version 2.0 (referred to as RAI User’s Manual)

0. Independent - No help or staff oversight - OR- Staff help/oversight provided only one or two times during the last 7 days.

1. Supervision - Oversight, encouragement, or cueing provided 3 or more times during last 7 days -OR- Supervision (3 or more times) plus physical assistance provided, but only 1 or 2 times during last 7 days.

2. Limited Assistance - Resident highly involved in activity, received physical help in guided maneuvering of limbs or other non weight-bearing assistance on 3 or more occasions -OR- limited assistance (3 or more times), plus more weight-bearing support provided, but for only 1 or 2 times during the last 7 days.

3. Extensive Assistance - While the resident performed part of activity over last 7 days, help of following type(s) was provided 3 or more times: -- Weight-bearing support provided 3 or more times; -- Full staff performance of activity (3 or more times) during part (but not all) of last 7 days.

4. Total Dependence - Full staff performance of the activity during entire 7 day period. There is complete non-participation by the resident in all aspects of the ADL definition task. If staff performed an activity for the resident during the entire observation period, but the resident performed part of the activity himself/herself, it would not be coded as a “4” (Total Dependence).

0. No Setup or Physical Help from Staff

1. Setup Help Only - The resident is provided with materials or devices necessary to perform the activity of daily living independently.

2. One Person Physical Assist 3. Two+ Persons Physical Assist

8. ADL Activity Did Not Occur During the Entire 7 Day Period -Over the last 7 days, the ADL activity was not performed by the resident or staff. The particular activity did not occur at all.

Restorative Program Requirements  measurable objectives  interventions  evidence of periodic evaluation by a licensed nurse

Resident Assessment Protocol: Activities of Daily Living – Functional Rehabilitation Potential pages C Refer to: MDS RAI User’s Manual

Bed Mobility - How the resident moves to and from a lying position, turns side to side, and positions body while in bed, in a recliner, or other type of furniture the resident sleeps in, rather than a bed.

Transfer - How the resident moves between surfaces - i.e., to/from bed, chair, wheelchair, standing position. Exclude from this definition movement to/from bath or toilet, which is covered under Toilet Use and Bathing.

Walking in Room: How the resident walks between location in his/her room.

Walk in corridor: How the resident walks in corridor on unit

G8 ADL Functional Rehabilitation Potential

Locomotion on Unit - How the resident moves between locations in his or her room and adjacent corridor on the same floor. If the resident is in a wheelchair, locomotion is defined as self-sufficiency once in the chair.

Scoring ADL Self Performance Refer to the MDS RAI User’s Manual Flow chart on page 3-90

Locomotion Off Unit - How the resident moves to and returns from off unit locations (e.g., areas set aside for dining, activities, or treatments). If the facility has only one floor, locomotion off the unit is defined as how the resident moves to and from distant areas on the floor. If in a wheelchair, locomotion is defined as self-sufficiency once in chair.

Nursing Rehabilitation/ Restorative Care Section P3

Dressing: How the resident puts on, fastens and takes off all items of street clothing, including donning/removing prosthesis

G7 Task Segmentation

Eating: How the resident eats or drinks (regardless of skill). Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition)

Toilet Use - How the resident uses the toilet room, commode, bedpan, or urinal, transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, and adjusts clothes. Do not limit assessment to bathroom use only. Elimination occurs in many settings and includes transferring on/off the toilet, cleansing, changing pads, managing an ostomy or catheter, and clothing adjustment.

The toileting activity subtask consist of: Hands-on assist to adjust clothing Weight-bearing assist to lower her to the seat Cleaned self independently Stood up from toilet with assistive device Pulled pants up independently

Urinary catheter Incontinent briefs for bowel incontinence Check and change q2h and prn

Appliances and Programs H3

Any Scheduled Toileting Plan: Scheduled Toileting Program including: organized, documented monitored and evaluated

Bladder Retraining Program Assessment Documented Plan of Care Communication to resident and care givers Scheduled times and approaches Evaluation of the plan Periodically reviewed and documented

Personal Hygiene - How the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, and washing/drying face, hands, and perineum.

Refer to the RAI User’s Manual Section 1.12 Completion of the RAI Pages 1-17 thru 1-19

Participants in the assessment/process have the requisite knowledge to complete an accurate and comprehensive assessment conducted or coordinated by an RN who signs and certifies the completion of the assessment. The attending physician is an important participant in the process.

The assessment process: identifies resident’s problems, needs, strengths, and risk factors

Section 1.12 Completion of the RAI pages 1-17 thru 1-18 Section 1.13 Sources of Information for Completion of the MDS pages 1-18 thru 1-19 Refer to the RAI User’s Manual

Section 1.14 CMS Clarification Regarding Documentation Requirements pages 1-23 thru 1-24

The process of information gathering should include: Direct observation Communication with direct caregivers Consult all shifts Review relevant information in the resident’s clinical record Consult with family members with direct knowledge