1. Catherine R. “Cat” Selman, BS The Healthcare Communicators, Inc. www.thehealthcarecommunicators.com © 2014, The Healthcare Communicators, Inc. – All rights reserved.

3.  Federal regulations require that (1) the assessment accurately reflects the resident’s status, (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

4.  However, nursing homes are left to determine (1) who should participate in the assessment process, (2) how the assessment process is completed, and (3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within the RAI manual.

5.  Given the requirements of participation of appropriate health professionals and direct care staff, completion of the RAI is best accomplished by an interdisciplinary team (IDT) that includes nursing home staff with varied clinical backgrounds, including nursing staff and the resident’s physician.  Such a team brings their combined experience and knowledge to the table in providing an understanding of the strengths, needs and preferences of a resident to ensure the best possible quality of care and quality of life.

6. Care Area Assessment  The MDS alone is not a comprehensive assessment.  It is used for preliminary screening to identify potential resident issues/conditions, strengths, and preferences.  Facilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable.

7.  The goal of the CAA process is to guide the IDT through a comprehensive assessment of a resident’s functional status.  Functional status differs from medical or clinical status in that the whole of a person’s life is reviewed with the intent of assisting that person to function at his or her highest practicable level of well-being.

8.  The CATs (Care Area Triggers) are specific response options from the MDS that are indicators of 20 particular care areas that affect nursing home residents.  When a trigger is entered as the response on a resident’s MDS, additional assessment and review of the care area are required to determine the status of the issue. Thus,  The CATs and CAAs form a critical link between the MDS and care planning.

9.  Triggers identify residents who have or are at risk for developing specific functional issues/conditions and require further evaluation.  A CAT provides a starting point for care planning and should be used in combination with other assessment and care planning information.  A CAA may define several MDS items or sets of items as triggers (CATs).  Only one of the trigger definitions must be present for a CAA to be triggered, although for many CAAs, each of the specific trigger items that are present must be investigated

10.  The specific MDS response indicates that clinical factors are present that may or may not represent a condition that should be addressed in the care plan.  CATs merely provide a “flag” for the IDT members, indicating that the care area must be assessed completely prior to making care planning decisions.  When the resident’s status on a particular MDS item(s) matches one of the CATs, the CAA is triggered, requiring an in-depth assessment.

11. 1.Potential Problems:  Suggest the presence of a problem that warrants additional assessment and consideration of a care plan intervention.  Usually include clinical factors commonly seen as indicative of possible underlying problems and well understood by nursing home staff.  For example, whether underlying behavioral symptoms can be minimized or eliminated by treatment of the underlying cause (e.g., agitated depression).

12. 2.Broad Screening Triggers:  Assist staff in identifying hard-to-diagnose problems.  Because some problems are often difficult to assess in the elderly nursing home population, certain triggers have been broadly defined and consequently may have a fair number of false positives  Examples include factors related to delirium or dehydration.  Experience, however, has shown that many residents who have these problems were not identified prior to having been triggered for review.

13. 3.Prevention of Problems These factors assist staff in identifying residents at risk of developing particular problems.  Examples include risk factors for falling or developing a pressure ulcer.  “At risk” – will the resident decline or deteriorate if this issue is not addressed on the care plan

14. 4.Rehabilitation Potential  Attempts to identify candidates with rehabilitation potential.  Not all triggers identify deficits or problems. Some triggers indicate areas of resident strengths.  Gives consideration to programs that improve a resident’s functioning or minimize decline.  For example, MDS item responses indicating that “resident believes he or she is capable of increased independence in at least some ADLs” (Section G) may focus the assessment and care plan on functional areas most important to the resident or on the area with the highest potential for improvement.

15.  Reviewing a triggered CAA means doing an in-depth, resident-specific assessment of the triggered condition in terms of the potential need for care plan interventions.  Is used to glean information needed to fully understand a resident’s condition.  After completing the assessment, analyzing the information collected, and drawing conclusions about the causes and factors contributing to the care area as well as risk factors for this resident, the next step is to develop a resident-specific care plan based directly on these conclusions.

16. Care Area Assessment  Each care area comprises: (1) an introduction that provides general information about the issue or condition and (2) a list of items and responses from the MDS that are considered CATs for the issue or condition.  Each triggered CAA must be assessed further to facilitate care plan decision making, but it may or may not represent a condition that should be addressed in the care plan.

17. Care Area Assessment  In previous versions of the RAI, Resident Assessment Protocols (RAPs) were mandated as the tools for completing the assessments of the triggered care areas.  For MDS 3.0, no specific tool is mandated as long as the tools are current and founded on evidence-based or expert-endorsed research, clinical practice guidelines, and resources.

18. CAAs 1.Delirium 2.Cognitive Loss/Dementia 3.Visual Function 4.Communication 5.Activity of Daily Living (ADL) Functional/ Rehabilitation Potential 6.Urinary Incontinence and Indwelling Catheter 7.Psychosocial Well-Being 8.Mood 9.Behavioral Symptoms 10.Activities 11.Falls 12.Nutritional Status 13.Feeding Tubes 14.Dehydration/Fluid Maintenance 15.Dental Care 16.Pressure Ulcer 17.Psychotropic Medication Use 18.Physical Restraints 19.Pain (New) 20.Return to Community Referral (New)

19.  CAA documentation should include the underlying causes, contributing factors, and unique risk factors related to the care area condition for the specific resident.  A risk factor increases the chance of having a negative outcome or complication.  A CAA should provide nursing home staff with comprehensive information for evaluating factors that may cause, contribute to, or exacerbate the triggered condition.

20.  If the condition is found to be a problem for the resident, the CAA information should assist the IDT in determining whether the care area issue/condition can be eliminated or reversed or, if not, whether special care must be taken to maintain a resident’s current level of functioning.

21.  The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what is the problem for this resident?  Causes and contributing factors.  Complications affecting or caused by the care area for this resident.  Risk factors that arise because of the presence of the condition that affect the staff’s decision to proceed to care planning.

22.  Factors that must be considered in developing individualized care plan interventions, including appropriate documentation to justify the decision to plan care or not to plan care for the individual resident.  Need for referrals or further evaluation by appropriate health professionals.  What research, resource(s), or assessment tool(s) were used in performing the CAA. A source(s) need only be cited if it is not already cited as the standard source(s) used for this CAA by facility policy.  Completion of Section V (CAA Summary; see Chapter 3 for coding instructions) of the MDS.

23.  Per regulatory mandate: the resident’s assessment must be conducted or coordinated by a registered nurse (RN) with the appropriate participation of health professionals.  It is common practice for facilities to assign specific MDS items or portion(s) of items (and subsequently CAAs associated with those items) to those of various disciplines.

24. Normal communication involves related activities, including:  expressive communication (making oneself understood to others, both verbally and via non-verbal exchange) and  receptive communication (comprehending or understanding the verbal, written, or visual communication of others).

25.  While behavior may sometimes be related to or caused by illness, behavior itself is only a symptom and not a disease.  Only identifies certain behaviors - is not intended to determine the significance of behaviors, not whether they are problematic and need an intervention.  Understanding the nature of the issue/condition and addressing the underlying causes have the potential to improve the quality of the resident’s life and the quality of the lives of those with whom the resident interacts.

26. Review of Indicators of Behavioral Symptoms

27.  Sadness and anxiety are normal human emotions, and fluctuations in mood are also normal.  Mood states (which reflect more enduring patterns of emotions) may be become as extreme or overwhelming as to impair personal and psychosocial function.  Mood disorders such as depression reflect a problematic extreme and should not be confused with normal sadness or mood fluctuation.  The mood section of the MDS screens for—but is not intended to definitively diagnose—any mood disorder, including depression.

28.  Involvement in social relationships is a vital aspect of life -most adults have meaningful relationships with family, friends, and neighbors.  When relationships are challenged, it can cloud other aspects of life.  Decreases in a person’s social relationships may affect psychological well-being and have an impact on mood, behavior, and physical activity.

29.  Declines in physical functioning or cognition or a new onset or worsening of pain or other health or mental health issues/conditions may affect both social relationships and mood.  Psychosocial well-being may also be negatively impacted when a person has significant life changes such as the death of a loved one.

30.  In the right column the facility can provide a summary of supporting documentation regarding the basis or reason for checking a particular item. This could include the location and date of that information, symptoms, possible causal and contributing factor(s) for item(s) checked.

31.  Step 6: Analyze the findings in the context of their relationship to the care area and standards of practice. This should include a review of indicators and supporting documentation, including symptoms and causal and contributing factors, related to this care area. Draw conclusions about the causal/contributing factors and effect(s) on the resident, and document these conclusions in the Analysis of Findings section.

32.  Step 8: In the Care Plan Considerations section, document whether a care plan for the triggered care area will be developed and the reason(s) why or why not.  NOTE: An optional Signature/Date line has been added to each checklist. This was added if the facility wants to document the staff member who completed the checklist and date completed.

33. Triggering Conditions (any of the following): 1.Resident has little interest or pleasure in doing things as indicated by: D0200A1 = 1 2.Staff assessment of resident mood suggests resident states little interest or pleasure in doing things as indicated by: D0500A1 = 1

34. Triggering Conditions (any of the following): 3.Any 6 items for interview for activity preferences has the value of 4 (not important at all) or 5 (important, but cannot do or no choice) as indicated by: Any 6 of F0500A through F0500H = 4 or 5 4.Any 6 items for staff assessment of activity preference item L through T are not checked as indicated by: Any 6 of F0800L through F0800T = not checked

35. Review of Indicators of Activities

48. Input from resident and/or family/representative regarding the care area. (Questions/Comments/ Concerns/Preferences/Suggestions)

49. Analysis of FindingsCare Plan Considerations Review indicators and supporting documentation, and draw conclusions. Document: Description of the problem; Causes and contributing factors; and Risk factors related to the care area. Care Plan Y/N Document reason(s) care plan will/ will not be developed.

50. Referral(s) to another discipline(s) is warranted (to whom and why): ______________________ _______________________________________________ ______________________________________________________________________ Information regarding the CAA transferred to the CAA Summary (Section V of the MDS):  Yes  No

51. Information from the assessment should be used to:  identify residents who have either withdrawn from recreational activities, or  who are uneasy entering into activities and social relationships,  to identify the resident’s interests, and  to identify any related possible contributing and/or risk factors.

52. The next step is to develop an individualized care plan based directly on these conclusions. The care plan should focus on: addressing the underlying cause(s) of activity limitations, and the development or inclusion of activity programs tailored to the resident’s interests and to his or her cognitive, physical/functional, and social abilities and improve quality of life.

53.  Written documentation of the CAA findings and decision-making process may appear anywhere in a resident’s record.  It can be written in discipline-specific flow sheets, progress notes, the care plan summary notes, a CAA summary narrative, etc.  Nursing homes should use a format that provides the information as outlined in the RAI manual and the State Operations Manual (SOM).  If it is not clear that a facility’s documentation provides this information, surveyors will ask facility staff to provide such evidence.

54.  No matter where the information is recorded, use the “Location and Date of CAA Documentation” column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision-making documentation can be found in the resident’s record.  Also indicate in the column “Care Plan Decision” whether the triggered care area is addressed in the care plan.

55. Assessment (MDS) Decision-Making (CAA) Care Plan Development Care Plan Implementation Evaluation

56.  The care plan is driven not only by identified resident issues and/or conditions but also by a resident’s unique characteristics, strengths, and needs.

57.  The IDT uses clinical problem solving and decision making steps to make decisions. The team may find during their discussions that several problematic issues and/or conditions have a related cause.  Or, they might find that they stand alone and are unrelated.  Goals and approaches for each problematic issue and/or condition may overlap, and consequently the IDT may decide to address the problematic issues and/or conditions collectively in the care plan.

58.  After assessing the resident, staff may decide that a triggered condition does not affect the resident’s functioning or well-being and therefore should not be addressed on the care plan.

59.  The existence of a care planning issue (i.e., a problematic issue and/or condition, need, or strength) should be documented as part of the CAA review documentation.  There are various options for documentation; for example, it may be done by individual staff members who have completed assessments or have participated in care planning, or as a summary note by members of the IDT.

60.  In some cases, a resident may decline particular services or treatments that the IDT believes may assist him or her to attain the highest practicable level of well-being.  In such cases, the resident’s wishes should be honored and documented in the clinical record and alternatives should be offered before the care plan is finalized.

61.  The IDT should identify and document the functional and behavioral implications of identified problematic issues and/or conditions, limitations, maintenance levels, improvement possibilities, and so forth (e.g., how the condition is a problem for the resident, how the condition limits or jeopardizes the resident’s ability to complete activities of daily living, or how the condition somehow affects the resident’s well-being).

62.  The IDT agrees on intermediate goal(s) that will lead to outcome objectives.  The intermediate goal(s) and objectives must be pertinent to the resident’s condition and situation (i.e., not just automatically applied without regard for their individual relevance), measurable, and have a time frame for completion or evaluation.

63.  The IDT, with input from the resident, family and/or resident representative, identifies specific, individualized steps or approaches that will be taken to help the resident achieve his or her goal(s).  These approaches serve as instructions for resident care and provide for continuity of care by all staff.  Precise and concise instructions help staff understand and implement interventions by consistently.

64.  The goals and their accompanying approaches should be communicated to other direct care staffs who were not directly involved in developing the care plan.  The effectiveness of the care plan must be evaluated from its initiation and modified as necessary.

65.  Changes to the care plan should occur as needed in accordance with professional standards of practice and documentation (e.g., signing and dating entries to the care plan).  IDT members should communicate as needed about care plan changes.

66.  A separate care plan is not necessarily required for each area that triggers a CAA.  For example, if impaired ADL function, mood state, falls and altered nutritional status are all determined to be caused by an infection and medication-related adverse consequences, it may be appropriate to have a single care plan that addresses these issues in relation to the common causes.

67.  Quality of life can be greatly enhanced when care respects the resident’s choice regarding anything that is important to the resident.  Interviews allow the resident’s voice to be reflected in the care plan.  Information about preferences that comes directly from the resident provides specific information for individualized daily care and activity planning.

68.  Care planning should be individualized and based on the resident’s preferences.  Care planning and care practices that are based on resident preferences can lead to improved mood, enhanced dignity, and increased involvement in daily routines and activities.

69.  Because residents may adjust their preferences in response to events and changes in status, the preference assessment tool is intended as a first step in an ongoing dialogue between care providers and the residents.  Care plans should be updated as residents’ preferences change, paying special attention to preferences that residents state are important.

70.  These questions will be useful for designing individualized care plans that facilitate residents’ participation in activities they find meaningful.  Preferences may change over time and extend beyond those included here. Therefore, the assessment of activity preferences is intended as a first step in an ongoing informal dialogue between the care provider and resident.  As with daily routines, responses may provide insights into perceived functional, emotional, and sensory support needs.

71.  Caregiving staff should use observations of resident behaviors to understand resident likes and dislikes in cases where the resident, family, or significant other cannot report the resident’s preferences. This allows care plans to be individualized to each resident.

72.  CMS MDS 3.0 Web Site www.cms.hhs.gov/NursingHomeQualityInits/ 25_NHQIMDS30.asp  You may submit questions regarding the MDS 3.0 directly to CMS: MDSQuestions@cms.hhs.gov

74. Catherine R. “Cat” Selman, BS The Healthcare Communicators, Inc. 601.497.9837 E-mail: catselman@aol.com www.thehealthcarecommunicators.com www.catselman.com