TEXAS HEALTH & HUMAN SERVICES COMMISSION OFFICE OF INSPECTOR GENERAL REVIEW OF RESTORATIVE PROGRAMS SEPTEMBER 22, 2014

Transcription

1 OFFICE OF INSPECTOR GENERAL TEXAS HEALTH & HUMAN SERVICES COMMISSION OFFICE OF INSPECTOR GENERAL REVIEW OF RESTORATIVE PROGRAMS SEPTEMBER 22, 21

2 OFFICE OF INSPECTOR GENERAL REVIEW RESTORATIVE PROGRAMS TOILETING PROGRAMS TURNING/REPOSITIONING PROGRAMS I

3 Restorative nursing program refers to nursing interventions that promote the resident s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The following criteria for restorative nursing programs must be met in order to code 5 per the RAI: Measureable objective and interventions must be documented in the care plan and in the medical record. If a restorative nuising program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident s medical record. Evidence of periodic evaluation by the licensed nurse must be present in the resident s medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity. A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents. Restorative nursing does not require a physician s order. Nursing homes may elect to have licensed rehabilitation professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services. In situations where such services do not actually require the involvement of a qualified therapist, the services may not be coded as therapy in item, Therapies, because the specific interventions are considered restorative nursing services (see item, Therapies). The therapist s time actually providing the maintenance service can be included when counting restorative nursing minutes, Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs. (There are no changes in the RAI version 1.12 released 9/17/21) Per the RAI, there are 1 (ten) identified Restorative areas. 5A, Range of Motion (Passive): Code provision of passive movements in order to maintain flexibility and useful motion in the joints of the body. These exercises must be individualied to the resident s needs, planned, monitored, evaluated and documented in the resident s medical record. 2

4 58, Range of Motion (Active): Code exercises performed by the resident, with cueing, supervision, or physical assist by staff that are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. Include active ROM and active-assisted ROM. (For both active and passive range of motion: movement by a resident that is incidental to dressing, bathing, etc., does not count as part of a formal restorative nursing program. For inclusion in this section, active or passive range of motion must be a component of an individualied program that is planned, monitored, evaluated, and documented in the resident s medical record. Range of motion should be delivered by staff who are trained in the procedures). OOSOOC, Splint or Brace Assistance: Code provision of (1) verbal and physical guidance and direction that teaches the resident how to apply, manipulate, and care for a brace or splint; or (2) a scheduled program of applying and removing a splint or brace. These sessions are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. (For splint or brace assistance: assess the resident s skin and circulation under the device, and reposition the limb in correct alignment), Training and Skill Practice: Activities including repetition, physical or verbal cueing. and/or task segmentation provided by any staff member under the supervision of a licensed nurse. 5, Bed Mobility: Code activities provided to improve or maintain the resident s self-performance in moving to and from a lying position, turning side to side and positioning himself or herself in bed. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 5E, Transfer: Code activities provided to improve or maintain the resident s self-performance in moving between surtaces or planes either with or without assistive devices. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 5F, Walking: Code activities provided to improve or maintain the resident s self-performance in walking, with or without assistive devices, These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 3

5 5G, Dressing andlor Grooming: Code activities provided to improve or maintain the resident s self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 511, Eating and/or Swallowing: Code activities provided to improve or maintain the resident s self-performance in feeding oneself food and fluids, or activities used to improve or maintain the resident s ability to ingest nutrition and hydration by mouth. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 51, Amputationl Prosthesis Care: Code activities provided to improve or maintain the resident s self-performance in putting on and removing a prosthesis, caring for the prosthesis, and providing appropriate hygiene at the site where the prosthesis attaches to the body (e.g., leg stump or eye socket). Dentures are not considered to be prostheses for coding this item. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. 5J, Communication: Code activities provided to improve or maintain the residents self-performance in functional communication skills or assisting the resident in using residual communication skills and adaptive devices. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. (The time provided for items 5A-J must be coded separately, in time blocks of 15 minutes or more.) TAC: (c)(1 6)(C) For Nursing Rehabilitation/Restorative Care, code between ero and seven the number of days on which the technique, procedure, or activity was practiced for a total of at least 15 minutes during each 2-hour period during the look back period. This includes nursing interventions that assist or promote the recipient s ability to attain his or her maximum functional potential, but does not include procedures or techniques carried out by or under the direction of a qualified therapist(s), as identified in the Special Treatments, Procedures, and Programs section of the MDS. The nursing rehabilitation and/or restorative care must meet all of the following additional criteria. The look back period for items described in this subparagraph is seven days. (i) (n) Measurable objectives and interventions must be documented in the care plan and in the clinical record as observed during the look back period. Evidence of periodic evaluation by licensed nurse must be present in the clinical record.

6 (iii) Nurse assistants/aides must be trained in the techniques that promote recipient involvement in the activity. (iv) The activities must be carried out or supervised by identified members of the nursing staff. There must be documentation, including minutes, in the chnical record for the nursing rehabilitation and/or restorative care program as observed during the look back period. This does not include groups with more than four recipients per identified supervising helper or caregiver. There must be documented evidence that services provided in a group setting were provided to a group of four or less. 5

7 Note: Toileting programs are not listed as restorative programs but are counted in the RUG calculation. Toileting (or trial toileting) programs refer to a specific approach that is organied, planned, documented, monitored, and evaluated that is consistent with the nursing home s policies and procedures and current standards of practice. A toileting program does not refer to: simply tracking continence status, changing pads or wet garments, and random assistance with toileting or hygiene. BLADDER REHABILITATION! BLADDER RETRAINING A behavioral technique that requires the resident to resist or inhibit the sensation of urgency (the strong desire to urinate), to postpone or delay voiding, and to urinate according to a timetable rather than to the urge to void. PROMPTED VOIDING Prompted voiding includes (1) regular monitoring with encouragement to report continence status, (2) using a schedule and prompting the resident to toilet, and (3) praise and positive feedback when the resident is continent and attempts to toilet, HABIT TRAINING! SCHEDULED VOIDING A behavior technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident s voiding habits or needs. Look for documentation in the medical record showing that the following three requirements have been met: implementation of an individualied, resident specific toileting program that was based on an assessment the resident s unique of voiding pattern evidence that the individualied program was communicated to staff and the resident (as appropriate) and through a care verbally plan, flow records, and a written report notations of the resident s response to the toileting program and subsequent evaluations, as needed (Guidance for developing a toileting program may be obtained from sources found in Appendix C of the RAI) (There are no changes in the RAI version 1.12 released 911 7/21) 6

8 TAO: (c)(5) Oontinence Appliances and Programs. The look back period for items described in this paragraph is 1 days. (A) For Scheduled Toileting Plan, check if recipient is on any scheduled toileting program. The documentation must include a plan for bowel and/or bladder elimination whereby staff members at scheduled times each day either take the recipient to the toilet, give the recipient a urinal, or remind the recipient to go to the toilet. This includes bowel habit training and/or prompted voiding, but does not include changing wet garments. A program refers to a specific approach that is organied, planned, documented, monitored and evaluated. The recipient s toileting schedule must be in a place where it is clearly communicated, available to and easily accessible to all stall. The care plan must indicate the recipient is on a routine toileting schedule. (B) For Bladder Retraining Program, check if recipient is on any bladder retraining program that is a retraining program to teach the recipient to consciously delay urinating or to resist the urge to urinate. The care plan must include individualied goals and approaches that is organied, planned, documented monitored, and evaluated. 7

9 Another program affecting RUG calculations is found in Section M. M12C Turning/Repositioning Program: Includes a consistent program for changing the resident s position and realigning the body. Program is defined as a specific approach that is organied, planned, documented, monitored, and evaluated based on an assessment of the resident s needs. The turning/repositioning program is specific as to the approaches for changing the resident s position and realigning the body. The program should specify the intervention (e.g., reposition on side, pillows between knees) and frequency (e.g., every 2 hours). Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention. (There are no changes in the RAI version 1.12 released 9/17/21) TAC: (c)(12)(C) Turning/repositioning program, to include a continuous, consistent program for changing the recipient s position and realigning the body. There must be a specific approach that is organied, planned, documented, monitored, and evaluated; 8

10 NURSING RESTOR.A VE CARE PROGRAM EX - PLAN Oveis.ght, Resident Name: Room: Month and i ear of Service SECTION I - PLAN OF CARE Knioretive Tech,o que {MOS S.cnoo P)j a/b ROM Passive 3/or Act,ve C WI C Spiint or brace AssisLanc Bed Mobikly &;or Wallong Training Trans(e Tiainrng 9 Dressng or Grooming naming h Eatng or Swallowing training I ArnputatiomvProsthesms Care Communication Training k Toileting Prograin/Wadier Training The Goal must be 15 minutes or more for 7 days per week Group activities are limited to four Residents or less per Team Member DATE PLAN INITIATED GOAL iusi&.ntwlwca1nplav. DL wtdvu.nltect gctffau&tetce gdntwj,nave cthota APPROACH WITH FREQUENCY 1 Regde.nt will pecxnn vj/evav.t2-adls wch LL.yuc,wt.on je t et p qd 15 2 R al&vtt wdl wav./wkd w tffpen uon jd x- bc) fr t 15.nate. NURSE SIGNATURE DATE NOTES Monthly Review - Key A. Is the Plan of Care Appropriate? N Independent - No help or staff oversight (no mouth, hands. or eye.) B. Aie Changes to the Program Recommended? Are Changes Recommended to the Goats? Ate Changes Recommended to the Appfoaches2 Y Y Supervision - encouragement, or cueing provided (mouth eyes. no hands) Limited Assistance- Resident highly involved in activity. It yes to B, UPDATE NEXT MONTftS SECTION WITH THE CHANGES. C. Continue Program? Discontinue Program? OF CARE received physical help in guided maneuvenng of knits or other non weight-tearing assistance (hands used for setup but no itt-ny w weight tanng) Extensive Assistance -While the resident pci-forms part of activity Jcensed StaWnaWre Date eight-tearing support is provided iitcoy or.r.eighl be&imrg jnivpari of tie flsi.jtnli Iota! Dependence - Fuii staff performance of the activity 9

11 Example #1 Goal #1 is identified as related to.q which is identified in the grid as Dressing or Grooming Training. The actual states complete goal will ADLs with limited assistance. There is no description of which ADLs. RAI: Code activities provided to improve or maintain the resident s self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualied to the resident s needs, planned, evaluated, and monitored, documented in the resident s medical record. Goal #2 is related to Walking Training- The goal states will move about environment with supervision. What environment, in room or throughout facility? How will the resident move? Walking or in a wheelchair? How can you measure supervision? RAI: Code activities provided to improve or maintain the resident s self-performance in walking, with or without assistive devices. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. Per RAI, page -33, the time provided for items 5A-J must be coded separately, in time blocks of 15 minutes or more. Review: 1. Goals #1 and #2 have no measurable objectives. The goals are not individualied to the resident. Example of a measurable objective: Mrs. Jones will comb her hair and apply her lipstick daily with verbal encouragement. Example ala measurable intervention: Mrs. Jones will do Range of Motion exercises 15 minutes daily to fingers, wrists and elbows to maintain joint flexibility for grooming. 2. This example does not have a document recording the time spent on each goal. Since there are two techniques addressed, the expectation is the documentation would demonstrate the time and # of days for each technique. 3. The documentation would clearly identify the staff providing the services. 1

12 , The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly code the MDS. Reviewing MDS 3. with facility documentation which uses terminology from MDS 2. put the reviewer and facility in possible risk situations. 11

13 No Resident NURSING RESTORATIVE CARE PROGRAM Resident Name: Room: Month and Year of Service I SECTION I - PLAN OF CARE RTEPMA/IMJTI,TW Full jrstorative Technique (MIDS Section P GOAL a/b ROM Passive &Jor Active JtrenjithJcs Jce%a tltø/ wabsncrea-se AEa tnprcn/e-transfrwy C Splint or Grace Assistance and ROA/ dif Bed Mobility &ior Walking Training wu actwe% prtcci pate- n- Mobility by a.t&ndaaon- w/wcwcer Transfer Training WCtJvSBS I atae-255o ft g Dressing or Grooming Training h Eating or Swallowing Training Amputation/Prosthesis Care APPROCH WITh FREQUUNCY Communication Training k Toileung Program/Bladder Training I wt2pttv ewtro rccaeqd jfr AROAI, CA/A. to-aijiota- neea eth The Goal must be 15 minutes or more for 7 days per week 2 -wdtwalc-astntwa..lerto-disu.ng-rocrn-i ir2 inecdsperclii u itksr&ssste/ Group activities are limited to four Residents or less per Team Member CMVi ars-neede& NURSE SIGNATURE DATE NOTES: E help or staff oversight (no mouth, hands. ui eyes) A. Is the Plan ol care Appropnale? V N Independent - Ii Are Changes to the Program Recommended? Y N Supewision - Oversight, encouragement, or cueing provided Are Changes Recommended to the Goals? / N (mouth, eyes, no hands) highly involved in activity, Are Changes Recommended to the Approache V N Limited Assistance - If yes to B, UPDATE NEXT MONTh S SECTION 1- PLAN OF received physical help in guided maneuvering of limbs or other non WITH THE CHANGES. weight-beaiing assistance (hands used for set-up but no idling or C. Continue Program? V N weight bearing) Discontinue Program? Y N Extensive Assistance -While the resident pedorms pail of activity weight-bearing support is provided (lifting or weight hearing any part of the resident) a - ae:sus Licensed Staff Signature 1-te Date Total Dependence - staff perloimance at the activity Resident Name: Room Number Month and Year of Plan 12

14 Example #2 Goal#1: Relates to two restorative techniques: strength and flexibility will increase to improve transfers and ROM. How will you measure an increase, define baseline? How do you measure an improvement, against a baseline? Example of a measureable objective: Mrs. Jones will increase her performance during transfers from needing limited assistance to needing only supervision. Goal #2: This goal could be accepted, however, SBA and SGA are therapy abbreviations and are not defined in the key. A restorative program is a nursing program and should use nursing terms. Example rewording of Goal #2: Mrs. Jones will maintain the ability to walk 25-5 daily using a walker with limited assistance from staff. 1. This example does not have a document recording the time spent on each goal. Since there are three techniques addressed, the expectation is the documentation would demonstrate the time and # of days for each technique. Per RAI, page -33, the time provided for items 5A-J must be coded separately, in time blocks of 15 minues or more. 2. The documentation would clearly identify the staff providing the services. 3. The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly code the MDS. Reviewing MDS 3. with facility documentation which uses terminology from MOS 2. put the reviewer and facility in possible risk situations. 13

15 NURSING RESTOI? VE CARE PROGHAM :ii - PLAN Overs.ght. Resident Name: Room: Month and Year of Service SECTION I a/b - PLAN OF CARE Reslor.ii.e Teervuque thus SeoTon P1) ROM Passive War Active C Splint or Brace Asstaiice d/1 Bed Mobitty &/or Walking Trainng e Transfer Training 9 Dressing or Grooming Training h Eating or Swallowing Training I Amputation/Prosthesis Care Communication Training k Toileting Program/Bladder Training The Goal must be 15 minutes or more for 7 days per week Group activities are limited to four Residents or less per Team Member DATE PLAN INITIATED GOAL Re sictevt.t wla c tpletedl w.tk qfk1ptrvtswyv Rasient wdl be free of incantttwmt epiolbs flfli j d rfl 5 üc APPROACH WITH FREQUENCY 1 i&clet.t wcutpeorn v mcrncnlj/eianüig DL - wth cpe vtston E.wt vp qc& x 15 vnlnati* )C 2 Uasid&nt wca lxwtlapate ntwe rocyca*v bqbre a-nd afte-r neal- Lcd, xi 15 ntc.utte- 3), a1o_& - -,A i--oa. in )a-c-1.j Po 7ict,t -g2a.-ltq,c,tcpa.toc Y NURSE SIGNATURE DATE NOTES Monthly Review A. Is The Pan of Care Appropnate? V N B Ase Changes to Inc Program Recommenced? V N A:e Changes Remrnended to the Goals? V N Are Changes Remmended to the Approaches? V N If yes to B, UPDATE NEXT MONTHS SECTION I WITH THE CHANGES. OF CARL Key Independent. No help or stall oversight (no mouth, hands. or eyes) Supervision - ericouragemerl. UI CUCfl9 piovidi (mouth, eyes, no hands) Lim,ted Asststance. Resident highly livolved iii activity. received physical help in guided maneuvering of (in us or other non weignt bearing assistance (hands used for set-up but rio lifting or C. Continue Program? Disconunue Program? ryn N weight beating) Extensive Assistance -Wni.e the resident perloinis purl of acivity weight-bearing support is piovitled (Iiltng or weight beai.r.g Rensed OdYidifl Licensed Stat) Signature Title Date any part o1 the resident) Tots] Dependence Full staff performance at the act:vity

16 Example #3 This example contains three goals, each for a different technique with ditlerent requirements. Goal #1, per the provided key, refers to dressing and grooming. Per the HAL code activities are provided to improve or maintain the resident s self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualied to the resident s needs, planned, monitored, evaluated, and documented in the resident s medical record. As written, this goal is not measurable, not individualied, and does not address a specific ADL. Example of a measurable objective: Mr. Jones will shave himself daily with set up assistance only from staff. Goal #2 relates to toileting which has specific requirements. There is no documentation to support that the resident s toileting program meets the requirements of the HAl. Per HAl, page H-5, look for documentation in the medical record showing that the following three requirements have been met:.implementation of an individualied, resident-specific toileting program that was based on an assessment of the resident s unique voiding pattern.evidence that the individualied program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, and a written report.notations of the resident s response to the toileting program and subsequent evaluations, as needed Goal #3 is to maintain ambulatory status...what ambulatory status is to be maintained? Does resident use an assistive device to walk? Cane, walker, wheelchair? How far is the resident able to ambulate? Example of a measurable objective for ambulation: Mr. Jones will ambulate from his room to and from the dining room using a walker daily for the noon meal with verbal cueing from staff, 1. This example does not have a document recording the time spent on each goal. Since there are three techniques addressed, the expectation is the documentation would demonstrate the time and number of days for each technique. Per RAI, page -33, the time provided for items 5A-J must be coded separately, in time blocks of 15 minutes or more. 2. The documentation would clearly identify the staff providing the services. 15

17 3. The key in the upper left corner refers to Section P3 of the MDS and combines restorative techniques making it difficult to properly code the MDS. Reviewing MDS 3. with facility documentation which uses terminology from MDS 2. put the reviewer and facility In possible risk situations. 16

18 < CU C LU I : -D a. U, C, cc II a: U-, FE U, I - C cc Lii H w C-) F : F- -J : <-U : CD C/) Er: 2 C, LU : LU > H I U) u-i C, (I, D 2 <U C-> > 2: LU U) U 2: t I a I El LU ẕ J C-) < a V a < C > Cu - C < U a U I I s.. \ F C-) Ui Cl) c C, C, - j-j j cp IE S Ci, ) C-: ) ic.1 j j -fl p LU Lo o. <>11 -Th - : a: I Ui 3 Ui U) t3 t a, I- Cu U I U -C U U, -C N I a. UI U) r a n U -a. c c% a, -. r I ID -.,t n - - %,- 1 a, a, c ) n 1 #- 1 C,) Ui x C-) Ix I,> U -C C.> -C U Cu ft ft S %-_ S S I- S < Cu Cu,2 U a a a a E E B t ). -p C.>.> U> U a a 2: CU C a U) ci: a: - CU -a C a j < N -. C I, a, I ẕ a Cu OZ 3 U, 2. U -J C, I, Cu C, ci a C-> U-

19 Example # This example demonstrates three goals and three techniques, ambulation, spiint brace. and transfers. Please note the Nursing Restorative Program applies to the discipline of PT. Approach #1 is the same as Goal #1. Per RAI, page -33, the time provided for items 5A-J must be coded separately, in time blocks of 15 minutes or more. The reviewer is unable to determine which approach goes with which technique for coding the MDS. It appears all approaches go with all techniques and are unable to determine if the time requirement is met for all three programs. Goal #1 would be measurable for walking and could suffice as a measurable intervention. The requirements for splint/brace assistance are not met. Goal #2 and #3 are the same and address transfers. Example of a measurable objective: Sam will maintain lower extremity strength to transfer safely from bed to standing position independently, The exercise approaches are measurable for this goal. 1. This example does have a document recording the time spent on each goal. Since there are three techniques addressed, the expectation is the documentation would demonstrate the time and # of days for each technique which cannot be deciphered. 2. The documentation did clearly identify the staff providing the services before de-identification. 18

20 Nuraiij ReiLon a Cara Projram I - - jiuiilil and (r Tyi {PI u_ 1J U c U L. a 2- &n ot Care - DL ft tannkva nwlthi iljjlth(ufl (rtulñ±lufl kt[b U jaa Ii r Lh,CU C Ru.ji &A I,-iL.ii ir.. Q w.kwi a Otj nwqr a(1. ou U - D1O th dcr tjjfl a.au..a jwil1 )t..ps.., I,AIt Li - - r r 2L;:i; i rn ZrCii5TiUi Z1 VE P11Jiit5T1i5Iv lf7i1f1i I i Sii 1T51it II K 1 In u.. 19

21 Example #5 Neither goal nor approach are measurable and this would not be acceptable documentation for a restorative program. 2