MDS 3.0 RAI Manual v1.16 October 2018

Transcript

1 Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.16 October 2018

2 ’ Centers for Medicare & Medicaid Services Long- Term Care Facility Resident Assessment Instrument (RAI) User’s Manual October 2018 For Use Effective October 1, 201 8 Long -Term Care Facility Resident Assessment Instrument User’s Manual for Version 3.0 The is published by the Centers for Medicare & Medicaid Services (CMS) and is a public document. It may be copied freely, as our goal is to disseminate information broadly to -term care facilities. facilitate accurate and effective resident assessment practices in long According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. (Note: The RAI mandated by OBRA is exempt from this requirement.) The valid OMB control number for the Medicare Prospect ive Payment System SNF and Swing Bed information collection is 0938- 1140 and forms have been approved through January 30, 2020. The time s required to complete the information collection for the i tem sets are as follows: Item Set Estimated response time NP 51 minutes 39 minutes NOD NO/SO 26.52 minutes NSD 34.17 minutes NS/SS 14.03 minutes These times are estimated per response, including completion, encoding , and transmission of the information collection. If you have comments concerning the accuracy of the time estimates or suggestions for improving these forms, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.

3 TABLE OF CONTENTS AI) Chapter 1: Resident Assessment Instrument (R Overview ... 1-5 1.1 Content of the RAI for Nursing Homes ... 1-5 1.2 Completion of the RAI ... 1-6 1.3 Problem Identification Using the RAI ... 1-8 1.4 MDS 3.0 ... 1- 1.5 11 1.6 Components of the MDS ... 1- 12 ... 1- 13 1.7 Layout of the RAI Manual Protecting the Privacy of the MDS Data 1.8 15 ... 1- Chapter 2: Assessments for the Resident Assessment Instrument (RAI) 2.1 Introduction to the Requirements for the RAI ... 2-1 2.2 CMS Designation of the RAI for Nursing Homes ... 2-1 2.3 Responsibilities of Nursing Homes for Completing Assessments ... 2-2 Responsibilities of Nursing Homes for Reproducing and Maintaining 2.4 Assessments ... 2-6 2.5 Assessment Types and Definitions ... 2-8 Required OBRA Assessments for the MDS 2.6 ... 2-15 2.7 The Care Area Assessment (CAA) Process and Care Plan Completion ... 2- 41 2.8 The Skilled Nursing Facility Medicare Prospective Payment System Assessment Schedule ... 2- 42 2.9 MDS Medicare Assessments for SNFs ... 2- 50 2.10 Combining Medicare Scheduled and Unscheduled Assessments ... 2- 60 2.11 Combining Medicare Assessments and OBRA Assessments ... 2-65 2.12 Medicare and OBRA Assessment Combinations ... 2- 67 ... 2- 2.13 Factors Impacting the SNF Medicare Assessment Schedule 79 2.14 ... 2- 84 Expected Order of MDS Records Determining the Item ... 2- 87 2.15 Set for an MDS Record o the Item -by- 3: Overview t Chapter Item Guide to the MDS 3.0 3.1 Using this Chapter ... 3-1 Becoming Familiar with the MDS -recommended Approach ... 3-2 3.2 3.3 ... 3-3 Coding Conventions ... A-1 Identification Information Section A ... B-1 ing, Speech, and Vision Hear Section B Cognitive Patterns Section C ... C-1 Section D Mood ... D-1 Section E Behavior ... E-1 Section F ... F-1 Preferences for Customary Routine and Activities ... G-1 Section G Functional Status Functional Abilities and Goals...GG-1 Section GG Section H Bladder and Bowel ... H-1 Section I Active Diagnoses ... I-1 Section J Health Conditions ... J-1 Section K Swallowing/Nutritional Status ... K-1 Section L Oral/Dental Status ... L-1 Section M Skin Conditions ... M-1 Section N Medications ... N-1 Section O Special Treatments, Procedures, and Programs ... O-1 ... P-1 and Alarms Restraints Section P 2018 i Page October

4 Section Q ... Q-1 Participation in Assessment and Goal Setting (Reserved) S-1 Section S ... Care Area Assessment (CAA) Summary V-1 ... Section V Section X Request ... X-1 Correction Assessment Administration ... Z-1 Section Z Chapter 4: Care Area Assessment (CAA) Process and Care Planning Background and Rationale 4-1 4.1 ... 4.2 Overview of the Resident Assessment Instrument (RAI) and Care Area ... 4-1 Assessments (CAAs) What Are the Care Area Assessments (CAAs)? ... 4-2 4.3 4.4 What Does the CAA Process Involve? ... 4-3 4.5 Other Considerations Regarding Use of the CAAs ... 4-6 4.6 When Is the RAI Not Enough? 4-7 ... The RAI and Care Planning 4-8 4.7 ... CAA Tips and Clarifications ... 4-11 4.8 4.9 the Care Area Assessment (CAA) Resources ... 4-12 Using 4.10 The Twenty Care Areas ... 4-16 4.11 (Reserved) ... 4-42 Chapter 5: Submission and Correction of the MDS Assessments 5.1 Transmitting MDS Data ... 5-1 5.2 Timeliness Criteria ... 5-2 5.3 Validation Edits ... 5-4 5.4 Additional Medicare Submission Requirements that Impact Billing Under the ... SNF PPS 5-6 5.5 Correction Policy ... 5-7 MDS Correcting Errors in MDS Records That Have Not Yet Been Accepted Into the 5.6 5-8 ... QIES ASAP System Correcting Errors in MDS Records That Have Been Accepted Into the QIES 5.7 5-10 ASAP System ... Special Manual Record Correction Request ... 5-14 5.8 Chapter 6: Medicare Skilled Nursing Facility Prospective Payment System PPS) (SNF Background 6.1 6-1 ... Using the MDS in the Medicare Prospective Payment System 6-1 6.2 ... Resource Utilization Groups Version IV (RUG -IV) ... 6-2 6.3 Relationship between the Assessment and the Claim ... 6-5 6.4 6.5 SNF PPS Eligibility Criteria ... 6-22 6.6 RUG -IV 66 -Group Model Calculation Worksheet for SNFs ... 6-23 6.7 SNF PPS Policies 6-52 ... Non ... 6-53 6.8 -compliance with the SNF PPS Assessment Schedule Appendices Appendix A: ... A-1 Glossary and Common Acronyms Appendix B: State Agency and CMS Regional Office RAI/MDS Contacts ... B-1 Appendix C Care Area Assessment (CAA) Resources ... C-1 Appendix D: Interviewing to Increase Resident Voice in MDS Assessments ... D-1 Appendix E: PHQ -9 Scoring Rules and Instruction for BIMS (When Administered In Writing) ... E-1 Appendix F: MDS Item Matrix ... F-1 G-1 ... References Appendix G: 2018 ii Page October

5 Appendix H: MDS 3.0 Forms ... H-1 October 2018 Page iii

6 CMS’s RAI Version 3.0 Manual Acknowledgements CMS ACKNOWLEDGEMENTS Contribut ns, and stakeholders liste d below are ions provided by the numerous people, organiz atio r the very much acknowledged by CMS. Their colle past ctive hard work and dedication ove elopment, testing, wri and ongoing review and g, form atting, sever al ye tin ars in the dev ta tem Set, and MDS 3.0 Da maintenance of the MDS 3.0 RAI Manual, MDS 3.0 Data I ulted in a n ew RAI process th Speci creases c linic al relevancy, data fications have res at in acy, c ds more of the r esident voice to the a ssessm ent process. We larity, and notably ad accur wish ple th at have contributed to making thi s manual possible. Thank to give thanks to all of the peo you do to prom ote the ca re and se rvi ces to in dividuals in nurs you for the work om es. ing h Experts in Long Term Care Elizab • eth Ayello, PhD, RN Barbara Bat sen, PhD, RN, CWO CN • es-Jen Robert P. Connolly, M SW • Kate Denni son, RN, RA C- MT • • Linda Drummond, MSM • Rosemary Dunn, RN • Elaine Hic key, RN, MS Karen Ho • an, RN, MPH ffm • Christa Hojlo, PhD CT • Carol Job, RN RAC- • A, MSEd., RAC- MT Sheri Kenn edy, RN, B Steve Levenson, MD, CMD • Carol Maher , RN- BC, R AC • -CT Mich elle McDonald, RN, MPH • Jan McClear y, MSA, RN • • Dann Milne, PhD er Montag, R N, BSN, RAC- CT • Tracy Burg John Morr • is, PhD, MSW • Diane New man, RNC MSN, C RN P, FA AN ennif er Pett is, RN, BS, WCC • J • er, RN, C RN AC, RAC- CT Terry Ras • chon, RNP, MSN, MA Therese Ro • Debra Sali ba, MD, MPH • Rena Shephard, MHA, RN, R AC -MT, C -NE • C, W CC Ann Spenard, MSN, RN Pauline (Su e) Swalina, RN • • Mary Van de Kamp, MS /CCC- SLP • Nancy Whittenberg Sheryl Zimmerman, PhD • October 2018 Page 1-1

7 CMS’s RAI Version 3.0 Manual Acknowledgements Organizations and Stakeholders Academy of Nutrition and Dietetics • American Association of Nurse Assessment Coordinators • American Health Care Association • American Health Information Management Association • American Hospital Association • • American Medical Directors Association • American Nurses Association • Association of Health Facility Survey Agencies – RAI Panel • Commonwealth Fund • interRAI Kansas Department on Aging • • Leading Age • National Association of Directors of Nursing Administration/Long Term Care • National Association of Subacute and Post Acute Care • The National Consumer Voice for Quality Long Term Care State Agency RAI Coordinators and RAI Automation Coordinators • • State Quality Improvement Organizations • US Department of Veterans Affairs Contractors Abt Associates Rosanna Bertrand, PhD • • Donna Hurd, RN, MSN • Terry Moo re, BSN, MPH Telligen • Gloria Ba tts • eiland, BSN, RN Debra W • Jean Eby, BS • Debra Cory, BS • Kathy Langenberg, RN RAND Corporation • Joan Buchanan, PhD • Malia Jones October 2018 Page 1-2

8 CMS’s RAI Version 3.0 Manual Acknowledgements RTI International Roberta Constantine, RN, PhD • Rajiv Ramakrishnan, BA • • Nathaniel Breg, BA • Karen Reilly, Sc.D. Stepwise Systems, Inc • Robert Godbout, PhD • David Malitz, PhD Hendall Inc . • Terresita Gayden • Anne Jones • Galen Snowden Terese Ketchen • • Jessie Pelasara • Michael Harrup CMS • Brandy Barnette, MBA, RN, CCM • Ellen M. Berry, PT • Sara Brice -Payne, MS, BSN, RN • CMS Regional Office RAI Coordinators • Jemima Drake, RN • Shelly Ray, RN Marianne Culihan, RN • • Thomas Dudley, MS, RN • Penny Gershman, MS, CCC- SLP • Lori Grocholski, MSW, LCSW • Christine Grose, MS, RN • Renee Henry, MSN, RN • Alice Hogan, PMP • Alesia Hovatter, MPP • —Division of Advocacy and Special Issues Melissa Hulbert, Director • John Kane • —Division of Institutional Post -Acut e Care Jeanette Kranacs, Director • Sheila Lambowitz, Director (Retired) —Division of Institutional Post- Acute Care • Sharon Lash, MPH, MA, RN • , Medical Officer — Division of Chronic and Post -Acute Care Alan Levitt, MD • Shari Ling, MD Page 1- October 2018 3

9 CMS’s RAI Version 3.0 Manual Acknowledgements , Deputy Director —Division of Chronic and Post - • Stella Mandl, BSW, BSN, PHN, RN Acute Care Tara McMullen, PhD, MPH • Teresa M. Mota, BSN, RN, CALA , WCC • Mary Pratt, MSN, RN, Director • -Acute Care —Division of Chronic and Post • MaryBeth Ribar, MSN, RN • Karen Schoeneman, Director (Retired) — Division of Nursing Homes • John E. V. Sorensen Christina Stillwell- Deaner, RN, MPH, PHP • • Michael Stoltz • Jennifer Sutcliffe, RN, BSN, RAC -CT • Christine Teague, RN -BC, BS, RAC- CT • Daniel Timmel —Division of National Systems John Williams, Director • • Cheryl Wiseman, MPH, MS ognition for the deve Special Rec the RAI Manu al goes to E llen Berry, PT and lopment of Stella Man dl, BSW, B SN, PHN, R N. Without t heir ded ication, drive, and endless h ours of work this manual would not have c ome to frui tion. garding Questions re sented in in formation pre this Manual sh ould be di rect ed to your S tat e’s RAI Coordinat Please co nt inue to check our web si te f or more i nf or mation at: or. http - ms.gov/Medica re/Quality -Ini tiative s-Pat ient -As sess ment ://www.c ml. nits /MDS30RAIManual.ht Instru ments /NursingHo meQualityI Page 1- October 2018 4

10 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) RESIDENT ASSESSMENT INSTRUMENT CHAPTER 1: (RAI) Overview 1.1 anual is ear gui dance about how to use the Resident A ssessm ent this m to offer cl The purpose of ctly and e ffect ively to help provide appropri ate c Instru care to ment ( RAI) corre are. Providing -hos long -term care n eeds is co pital and llenging wor k. Clinic al ith post residents w mplex and cha nter viewing and c ritical t hinking skil ls, and a competence, observa ent exper tise tional, i ssessm all dis e r equired to develop indi vidua lized ca re plans. T he RAI helps nursing from ciplines ar f in tre ing de fini tive in formation on a re sident’s s e staf ngths and ne eds, which m ust be hom gather s sta in uali zed car e plan. It also a ssist vid ff with ev alua ting goal ac hi evement addressed an indi sing care plans a ccordin gly b y enabling t he nursing hom e to track and revi he changes in t resident’s process of problem iden tificat ion is integr ated w ith sound c linical s tatus. As the erven tions, the c lan beco mes each r eside nt’s unique path toward a chieving or m aintaining int are p ighest pr l-being. vel of wel r h his or he actical le viduals f f look at re nts hol isticall y—as indi e staf or wh om quality The RAI helps nursing hom side e and qual ity of car e are m utua lly signi ficant and nec essary. In terdi scip linary u se of the RAI of lif motes th pro mphasis on qual ity of care and q uality of l ife. Nursing hom es have f ound that is e erapy, occup scip etary, soci al work, physic al th uch as di ation al th erapy, speech involving di lines s athology, pha rmacy, and acti viti es in language p ost ered a m ore holis tic the RAI process has f approach resident c are and stren gthened te to communication. This i nterdis ciplina ry process am ience of t’s exper i nfluence on t cluding: also h elps to support t he spheres of care, in he resi den workplace pract ices, nursing hom e’s cu ltural and physic al environm ent, sta ff sat isfaction, the and hips, and tice deliv ery, s hared l eaders hip, f amily and co mmunity r elations cli nical care prac 1 l/Stat cal gov Federa tions. ernment regula e/lo proble Persons ge ter a nursing hom e because of neral ms with f uncti onal s tatus caused by ly en physic al de terio ration, c ognitive dec line, the ons et or ex acer bation of an acute illness or etimes, the individual condi elated f actors. S om other r ’s abi lity to m anage inde pendently tion, or has been l imited to the e xtent that s kil led nur sing, m edical t reatment, and/or reha bi lita tion is esto needed f he resi dent t o m aintain a nd/or r or t re f unction or to live saf ely f rom day to day. in the While we r ecognize that there are o ften unavoida ble de clines, par ticul arly last s tages of t re lif e, al rces and di sciplines m ust be used to e nsure tha esou sidents ach ieve the ssary r l nece lev el of f unctioning possible ( qual ity of care) and m aintain the ir sense of indivi dual ity highest and r lity of t rue f or both long -term residents l ife). This is esidents in a rehab ilitative program (qua nvironm cipating return to t heir pre vious e nvironm ent or anothe r e oice. ent of their ch anti 1.2 Content of the RAI for Nursing Homes t hr ee basic co he Mini mum Data Set ( MDS) Version 3.0, the The RAI consists of mponents: T Care Area Assess AI Utili zation Guidelines . The uti lization of the ment (CAA) process and the R 1 . Hea lth cent ric Advi sors : The Ho listic Approach to Transfor mational Ch ange (HA TCh ™). CMS NH QIO SC Contr act - Provid ence, RI. 2006 . Available from http://healthcentricadvisors.org/wp -content/uploads/2015/03/INHC_Final -Report_PtI . IV_121505_mam.pdf Page 1- October 2018 5

11 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) mponents of the inf or mation about a r esi dent’s f unc tional s tatus, st rengths, three co RAI yields ferences, as wel weaknesses, urther as sessment once proble ms l as o and pre ffering guidance on f ch co nt f lows natur ally into t he next as f oll ows: fied. Ea have been i denti mpone linical, Minimum A core s et of screen ing, c (MDS). and f unctiona l status • Data Set omm on de finitions and c oding ca elem ries, which f orms the ents, including c tego a co ent f or all re sidents of nur sing hom es cer tified to foundation of mprehensive assessm ate in Medic he MDS st Medica id. T he ite ms in t ticip andardi ze comm unicati on par are or es, between nur ms and condi within nur sing h om tions sing h om es, about re sident proble mes and out side agenci es. and between nursing ho ired subsets of data i tems for The requ each M ment and tr acking docum ent (e.g., Comprehensive , Quarterly, OBRA DS assess racking, P PS item sets be f ound in Appendix H. Discharge, Entry T ) can Care Area Assessment sist the a This pr ocess is des igned to as ssessor to • (CAA) Process. matica terp ret t he in formation recor ded on the MDS. Once a car e area has been syste lly in gered, n ursing hom e provide rs u se cur rent, e videnc e-bas ed cli nical re sources to trig ssessm ent of the pote ntia l probl em and deter mine whether or n ot to c are p lan conduct an a he clinician ocus on key i ssues ide ntifi ed during t he for it. The CAA process helps t to f ent process so t hat de cisio ns as to whe ther and how to int ervene can be exp lored assessm fic with the is exp lained in det ail in Chapter 4. S peci ident. The CAA process res components of the CAA process inc lude: esid mbination co es f or one or a — Care Area Triggers ( CATs) are s peci fic r ent respons of MDS elem ents. The trigge nts who have or are at r isk f or rs ide ntify reside fic f sessm tional probl ems and req uire f urt her as s peci ent. developing unc trigge is the f ur ther inve stig ation of red area s, to deter mine if — Care Area Assessment re ar ea trig gers r equire int erve ntions and car e planning. The CAA r esources a re the ca provided as a cour to f acil ities in Appendix C. These resources i nclude a tesy ay be help of W eb l inks that m sts and ful i n per forming the compilation checkli ent of a trigg ered care a assessm The use of these reso ur ces is not m andatory a nd rea. the list of Web links is ne ith er a ll-inclusi ve nor gover nm ent endorse d. — CAA Summary (Se ction V of the MDS 3.0) provides a lo cation f or doc um entation rigge of the care a rea( s) that have t red f rom the MDS and the deci sions m ade during the CAA process re garding whether oceed to c are planning. or not to pr nes provide lines. The Utili zation Guideli ation Guide i nstru ctions f or when and • Utiliz he RAI. These in clude i nstru ctions fo r co how to use t of the RAI as well as mpletion stru meworks for synthe sizing MDS and other c lini cal in formation (avai ctured fra le lab http://cms.hhs.gov/Regulations -and - from Guidance/Guidance/Manuals/downloads/som107ap_r.pdf ). 1.3 Completion of the RAI Over ti me, the various uses of the M DS have expanded. W hile its pri mary purpose a s an assessm ent t ool is t o iden tify r esident care proble ms that are ad dres sed in an indi vidua lized care or the Skilled Nursing Facility plan, da llected f rom MDS a ssessm ents i s also used f ta co Prosp ective Payment System (SNF PPS) Medica re rei mburse ment sys tem, many State Medica id om sing h e residents. ided to nur reim burse ment syste ms, and m onitori ng the qua lity of care prov Page 1- October 2018 6

12 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) MDS instr um ted for use by non- criti cal ac cess hospita ls with a swing The ent has also been adap ent to co the MDS f or rei mbursem agreement. They are required under S NF PPS. bed mplete Medicare and Medica id Payment Systems. The MDS contains i tems that re fle ct t • he acuity el of the resi dent, including diagnoses, t reat ments, and an evaluation of the lev nctiona ol to c lassi fy resident’s fu l status. The MDS is used as a data collection to re re sidents into RUGs (Res Medica ilization Groups). The RUG classi fication ource Ut system is used in SNF PPS for skilled nursing fa cilities, non- critical access hospit al swing bed programs, and in m any S tate Medic aid case mix paym ent syste ms to group reside nts into sim ilar re ories for the purposes of rei mburse ment. More detai led source usage categ in Chapters 2 and 6. Ple fer to t he Medica re information on the SNF PPS is provided ase re et- Only Manuals, including the Medica re Intern it Poli cy Manual, lo cated at Benef https://www.cms.gov/Regulations -and -Guidance/Guidance/Manuals/index.html for comprehensive in formation on SNF PPS, including but not lim ited to S NF coverage, SNF policies, and claim sing. s proces • Monito ring the Qua lity of Care. M DS assessment dat a are also used to monitor the es. MDS quali care in the na tion’s nursing hom ty of -based qua lity m easur es (QMs) we re ication staff in identifyi ng developed b y rese archers to as sist: ( 1) Sta te Su rvey and Certif potent ial care problems in a nursing hom lity e; (2) nursing home providers with qua ivities/ eff ursing hom e consumers in understanding the qua lity improvement act orts; (3) n ided by a nursing home; and (4) CMS with long-te rm quality monitoring and of care prov y evalu ates the usefulness of the QMs, which ma y be program planning. CMS continuousl modified in the future to enhance t heir effectiveness. • Consumer Access to N ursing Ho me Inform ation . Consum ers ar e al so able to acces s information about every Medicare- and -certified nursing home in the /or Medicaid ) country. The Home Compare tool ( www.medicare.gov/nursinghomecompare Nursing provides public a ccess to nursing hom e charact eris tics, s taffing and quali ty of care measures for ce rtif ied nursing hom es. egul The RAI pr ocess has m ultip le reg ula tory requirem ents. Federal r ations at 42 CFR 483.20 (b)(1)(xv iii ), (g), and (h) requir at e th s the resi ent accura tel y re flect essm den t’s status (1) the ass (2) ste red nurse conducts or co ord inates e ach a ssessm ent with the appr opria te a regi par ticip ation of health p rof essionals mmunication with the (3) essment proc ess includes dir ect obser vation, as well a s co the ass resident and dire ct care s taff on all shif ts. Nursing hom es are lef t to determine (1) who should part icip ate in the ass es sm ent process how the asse ssm ent process is co mpleted (2) October 2018 Page 1-7

13 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) how the asse ent in formation is docum ented w hile re maining in com pliance with the (3) ssm lations and the i requirements of the Federal ithin this nstru regu ctions contained w manual. fession Given the requirements lth pro parti als and di rect care s taff, of cipation of appropria te hea n int erdis ciplin ary team (IDT) that completion of the RAI is best a ccomplished by a includes e staff with varied nic al back gro unds, including nursing s taff and the resident’s nursing hom cli brings t r combined experience and ian. Such a team knowledge to the table in providing physic hei rengths, needs and prefer a r esident to en sure the best poss ible an understanding of the st ences of ty of care and q uality of lif e. It is i mportant to note that even nursing h om quali een es that have b gran te t he ted an RN waiver under 42 CFR 483.35(e) must provide an RN to conduct or coordina sm ent as c plete. assessment and sign off the asses om me ent r co lle cting in formation f rom m rate assessm so urces, so equires In addition, an accu ultiple andated b y regul atio ns. Those sources must include t he resident and dir ect ca re of which are m ff on all shifts, and should also in clude the re sident’s m sta ian, and fam ily, edical record, physic guardian, or signi app ropria te or acceptable. It i s important to note her e t hat ficant other as ould cover the same observation pe fied by the M DS ite ms on information obtained sh riod as speci sment, and should be val idated f or accuracy (what the resi the asses ctual st atus was dent’s a during that observation period) by the IDT c om pleting the ass essment. As such, nursing hom es are responsi e ent process have the requisit ble for ensur ing th at all par ticipa nts i n the ass essm knowledge t o co ate a ssessm ent. mplete an accur Whi pose speci fic docu mentation proced ures on nur sing hom es in co mpleting le CMS does not im entation that co ntributes to iden tif ica tion and co mmunication of a resi dent’s the RAI, docum problems, needs, and s trengths, that monitors the ir con dition on an on- going basis, and that records reatm ent, is a m atter of good clinical pract ice and an tr eatment and response to t expect ation of trained and lice nsed health care prof essionals. Good clinic al pr actice is an expect ation of CMS. As such, it is i mportant to n ote th at co mple tion of the MDS does not led as remove a nursing hom e’s respon sibil ity to d ocu ment a m ore detai sessment of par ticular issues relevant f or a re tion, documentation must substantia te a resi den t’s need f or sident. In addi -level are SNF PPS. vic es and the response to those ser vices f or the Medic Part A SNF ser Problem Identification Using the RAI 1.4 ians are gener ally Clinic identification proces s as pa rt of their pro fessional taught a problem education. For example, the nursing pro fession’s problem identif ication m odel is c all ed the nursing process, which consists of as sessment, diagnosis, out fica tion, planning, come identi ication models have sim implementation, and evaluation. All good problem identif steps to ilar those of the nursing proc ess. The RAI si mply provides a s truct ured, standa rdized approach for applying a proble m iden nursing homes. The RAI should not be, nor was it ever meant to be, an tif ication process in additional burden for nursing hom e staff. ss as follows: using the nursing proce etion of the RAI can be conceptu alized mpl The co October 2018 Page 1-8

14 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) Assessmen —Taking s tock of all o bservations, information, and knowledge about a resident a. t edical records, from all available sourc t’s family, and/or the resident, res es (e.g., m iden horized resent ativ e). ly aut rep legal guardian or other ing b. termining w ith the resi dent (resident’ s family and/or guardian or other Decision Mak —De horized rep resent ativ e), t he resi den t’s physic ian and the inter legal plin ary t eam , the ly aut disci ity, functiona a resid ent’s c linical issues and needs. Deci sion sever l impact, and scope of iew of ment in formation, in-depth understanding d by a rev the assess making should be guide iagno ses and co -morbidi of the resi reful consider ation of the tr iggered dent’s d ties, and the ca in the CAA process. Understanding the causes and r el ationships between a resident’s areas issues and needs and discove cli nical he “whats” and “whys” of the r esident’s cli nical ring t issues and needs; finding out who the resident ation f or i ncorpora ting his or is and consider interests, and lif estyle ic es i nto the deliv ery of care, is key to this step of the her needs, cho process. mining the expected o fica tion of Outc omes —Deter utcom es forms the bas is f or c. Identi ating r esident- specif ic goals and inte rven tions that are designed to help evalu residents achieve th goals. This also as sists the int erdi sciplin ary team in determining who needs to ose ted tif ica comes. Out comes iden be involved to support the expec tion rein forc es resident out ticip ized care tenet moting the reside nt’s act ive par individual ation in the proc ess. s by pro d. C are Planning lishing a cour se of action with input from the resi dent ( resi den t’s —Estab ily and/ ized ian or other leg all y author fam repre sent ative), resident ’s physi cian and or guard rdi scip linary te am that move s a resident t oward resi dent -specific goals util izing inte individual re sident str engths and inte rdisci plin ary exper tise; craf ting the “ how” of resident care. e. Imple mentation —Put ting that co urse of (speci fic in terven tions derived thro ugh action inte rdis ciplinary in dividuali zed care planning ) into motion by sta ff knowledgeable about the resident’ s care g oals and approa ches; ca rrying out the “how” and “when” of res ident care. —Crit f. Evaluation ical ly reviewing individua lized care plan goals, inter ventions and implementation in t erms of achieved comes as identi fied and a ssessing the need resident out y the ca terv entions) to adjust to chan ges in t he resident’s to modif re plan (i.e., change in ls, or i mprovem ent or decline. status, goa ollowing pathway illu The f a problem identif ication process flowi ng from MDS (and other str ates assessments), to the CAA decision e pl an developm ent, ca re pl an -making process, car implementation, and f inally to evalu ation. This m anual wi ll refer to th is p rocess t hrou ghout sever sions. al chapter discus If you look at the RAI process a s a solution ori ented and dy namic process, it b ecomes a r ichly pract ical means of help ing nursing hom e staff gather and an alyze in form ation in order to im prove a residen t’s qu ality of care and quali ty of lif e. The RAI o ffers a clear path t oward using October 2018 Page 1-9

15 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) bers of the int plin ary team in a proactive pro cess. There is absolut ely no reason to all mem erdisci AI process as an added task or view labor. another “lay er” of t the R inser it as s stru fully using the R uccess and th at it AI process cture is designed to The key to s is to underst esident ca re, i ncreas e a r esident’s active par ticip ation in car e, and promote the quali ty enhance r ’s li of a resident is occurs not only becau se it follows an inte rdis ciplinary proble m-solving fe. Th lso becau or other ff (across all s hif ts), residents and fam ilies (an d/or guar dian model, but a se sta (or othe ly aut legal resent ativ e) a nd physici ans horized r a uthorized hea lthc are profe ssional s as rep allowab le under sta te la w) are a ll involved in its “hands on” approach. T he resu lt i s a process that flows smoothly and allows for good communication and t racking of resi re. In short, i t dent ca works. Since the R implemented, nursing hom e staff who have applied the RAI process in AI has been anner we have di scussed have discover ed t hat it works in the f ollo wing ways: the m tive zed Care. W hile we wi ll discuss oth er posi • Residents Respond to Individuali responses to the RAI be low, there is none m ore persuasive or powerf ul th an good resident out comes both in terms of a resident’s qual ity of ca re and enhanced qual ity of li fe. Nursing home provi found that when resi dents acti vely p art icip ate in their care, ders have and car e plans refle ct appro pri ate resi den t-speci fic ap proaches to car e based on careful con sider ation of individu al problem s and causes, l inked with inp ut f rom residents, e), and t ativ sent he residents’ fa milies (and /or guard ian or other leg ally a uthorize d repre inte rdis ience d goal achievem ent and eith er th eir level ciplinary t eam, residents have exper at a s lower r ate. Nursing hom e staff of functioning has improved or has deteriora ted th at, as individua lized at ten tion incre ases, resident s atisf action wi th qual ity of lif e report ncreases. also i • S taff Co mmunication Has Beco me More Ef fective. When staf f members ar e inv olved in a resident’s ongoing a the deter mination and ssessment and have input into development of a resi dent’s c are plan, the commit ment to and the understanding of that care plan is enhanced. A ll l evels of staff, including nursing a ssistants, ha ve a stake in the process. Knowledge gained from ul examination of poss ible c auses and solutions of caref ff to hone the per forming the CAAs) chal leng es sta resident problems (i.e., from dent pro fessional skills of their di scipline as well as fo cus on the individua lity of the resi lity is acco and holis tically con sider how that individua e plan. mmodated in the car • n Care Has Increased. There has b een a dram atic Resident and Family I nvolvement i the f requen cy and nature of resident and fam ily involvement in the c are incr ease in ut has been pro vided on individual resi dent goals, needs, int erest s, planning process. Inp stren gths, problems, preference s, and lif est yle choices. When consider ing all of th is information, staf f members have a much bett er p icture of the resident, and residents a nd ter u fam ilies ha ve a bet nderstan ding of the goals and process es of care. • Increased Clarity of D ocumenta tion. When the approaches to achievi ng a speci fic goal are und erst ood and dis tinct, the need for voluminous documentation diminishes. ffectively Likewise, when staf bers are comm unicati ng e f mem am ong th em selves with ory notes dict respec t to resident care, repetit ive d ocu mentation is not ne ces sary and co ntra ecords have found do not occur. In addition, new staff, consultants, or others who review r 10 October 2018 Page 1-

16 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) creased c larity formation documented about a resident m akes tracking that the in of the in complish. utcomes easier to ac care and o ear gui dance, through instr uction and example, for the to offer cl The purpose of this manual is eby e staf f achieve the benef its l iste d above. effective use of the RAI, and ther help nursing hom with objecti ves set f orth in the Ins titute of Medi In keeping M) study co mpleted in 1986 cine (IO (Comm on Nursing Home Regulation, IOM) that m ade r ecommendations to improve the ittee ty of esid rsing homes, the RAI provide s each r quali ent with a standardized, care in nu essment. This tool ass comprehensive and reproducible ass es a res iden t’s abi lity to per form ess daily lif e functions, identi fies s igni ficant i mpai rm ents in a resident’s functiona l capacity, and provides opportuni tie s f or dir ident inter vie w. In essen ce, with an ac curat e RAI c om pleted ect res dent and can dical careg ivers have a genui perio tent recor ded “look” a t t he resi ly, ne and consis attend to th at re siden t’s needs with r eal istic goa ls in hand. Furthermore, with the co nsiste nt ap plication of item def initio ns, the RAI e nsures s tan dardi zed communication both within the nurs om e and between f aci liti es (e.g., other long-t erm care ing h facil ities or hospita ls). B asica lly, w hen everyone is spea king t he sam e language, the opportuni ty for misunderstanding or error is diminished consi derably. 1.5 MDS 3.0 vances in stic s, ad sident re In respons e t o changes in nursing hom e care, res ident ch arac teri assessm ent methods, and provider and consumer conce the MDS rns about the perform ance of es (CMS) co or Med ers f icaid Ser vic icare ntra cted with the RAND 2.0, the Cent & Med Universi ty to draf t re vis ions and na tionally test the MDS Version 3.0. Corporation and Harvard a synopsis of the goals and key findings as r epo Following is the Development & rted in Validation of a Revi sed Nursing Home Assessment Tool: MDS 3.0 final report (Sa liba and Buchanan, 2008). Goals The goals of the MDS 3.0 revision ar e to i ntroduc e advances in assessm ent m easures, i ncreas e the clinic al relevan ce o f ite ms, improve the ac curacy and va lidity of the tool, inc rease user ms. satis faction, and incr ease the resident ’s voice by introducing m ore resi dent in terv iew ite Providers, consumers, and other te chnical at MDS 3.0 th experts in nursing hom e care r equested revi linical uti lity, c larit y, and accu racy. CMS a lso wanted to sions focus on improving the tool’s c incr ease t he usabil ity of the inst rume nt while m aintai ning the abi lity to us e MDS data for quality rce ut measure reporting and Medica re S NF PPS rei mbursem ent (via r esou RU iliz ation group [ G] clas sif ication). ent and struc In addition to improving the cont the MDS, the RAN D/Harvard t eam also ture of aimed to improve user s atis faction. User at titu des are key deter minants of quality improvem ent implementation. Negati ve user att itudes toward t he MDS are of ten cited as a reason that nurs ing care planning. rgeted homes have not f ully i mplem ented the in form ation from the MDS into ta 11 October 2018 Page 1-

17 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) Methods challen ges p reviously id entif ied and to provide an em pirical To address m any of the issues and were i mplem foundation f or examining revisions to the MDS before they ented, the that incorpo engaged in a c ful i eam ati ve process are rated provid er and ND/Harvard t RA ter tif ic ad vances in cl inical knowl edge about screening consumer input, exper t consultation, scien ive i developm ment, CMS experience, and intens ent and testing by a nat ional and assess tem ministr inal n (VHA) consor tium. This proc ess a llowed the f ealth Ad ational Veterans H ation ting of MDS 3.0 to include well-developed and tes tem s. tes ted i The national valid ation and evalua tion of the MDS 3.0 included 71 community nursing h om es omes (764 residents (3,822 residents) and 19 VHA nursing h nal ly distribut ed throughout ), regio the United S to test and anal yze in ter-rater ag reement tat es. The evaluation was designed g h liabili ld- stand ard ( resea rch) n urses and bet ween nursin between go ome and gold- (re ty) idity of key secti ons, response rates for in terview i tems, anonymous f eedback standard nurses, val rom partici pating n urses, and tim on changes f mplete the MDS ass essment. In addition, the e to co nationa st design a llo wed co mparison of item dist ribut ions between MDS 3.0 and MDS 2.0 l te mapping into paym ent cells ( Saliba and Buchanan, 2008). and thus facilitated Key Findings for MDS 3.0 Improved R esident Inp ut • • ili ty Reliab and ccuracy Improved A • cr eased E fficiency In Improved Staff Satis fact ion and Perception of Cl inical U til ity • ore ef prov ements inc orpor ated in MDS 3.0 produce a m stru ficient ass essm ent in Im ment: b ette r quali formation was obtained in l ess ti me. Such gains should improve identif ication of ty in tems nce res iden t-f ocused car e planning. I n addi tion, inclusion of i resident needs and enha rs. These recogn ized in other c are set tings is li kely to en hance co mmunication among provide changes a cross the tool, signi ficant g ains refl ect the cu mulative e ffect of ding: inclu • use of m ore valid ite ms, • dire ct in clusion of resid ent reports, and ned item • improved clar ity of retai s. 1.6 Components of the MDS l re The MDS is co mpleted for al - or Me sidents in Medic are dicaid -cer tified nursing hom es and ssm non- access hos pitals w ith Me dicar e swing bed agreements. The mandated a sse criti cal ent schedule is discussed in Chapter 2. S tat es m ay also establish additional MDS requirements. For te RAI Coordinator (see t y speci fic in formation on State requ irem ents, please contac our Sta Appendix B). 12 October 2018 Page 1-

18 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) Layout of the RAI Manual 1.7 The layout of the RAI m anual i s as follows: • esident Ass essm ent Inst rum ent (RAI) Chapter 1: R • Chapter 2: Assessm ents f or the Res ident Assessm ent Instr um ent (RAI) • Chapter 3: Overview to the Item- by-Item Guide to the MDS 3.0 • Chapter 4: C are Area A ssessm ent (CAA) Process and Care P lanning • Chapter 5: Submission and Correction of the MDS Assessme nts (SNF P em ayment Syst PS) • Chapter 6: Medica re S killed Nursing Faci lity P rospect ive P Appendices • Appendix A: Glossary and Common Acrony ms • Appendix B: Stat e Agency and CMS Regional Off ice RAI/MDS Contacts • Appendix C: Care Area Assessm ent (CAA) Resources ents • Appendix D: Int erv iew ing to Increa se Resident Voice in M DS Asses sm When nd Instr uction f or BIMS ( Appendix E: PHQ-9 Scoring Rules a Adm inis tered In • Writing) • Appendix F: MDS Item Matrix • Appendix G: Ref erences Sets • Appendix H: MDS 3.0 It em 13 October 2018 Page 1-

19 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) Title Section Intent Obtain key information to uniquely identify each resident, nursing A Identification Information , type of record, and reasons for assessment. home and communicate the resident’s ability to hear, understand, Document Hearing, Speech, and B with others and whether the resident experiences visual , hearing or Vision speech limitations and/ or difficulties. Determine the resident’s attention, orientation, and ability to register C Cognitive Patterns and recall information. . signs and symptoms of mood distress D Mood Identify Identify behavioral symptoms that may cause distress or are E potentially harmful to the resident, or may be distressing or disruptive Behavior to facility residents, staff members or the environment. Preferences for Customary Obtain information regarding the resident’s preferences for his or her F daily routine and activities . Routine and Activities Assess the need for assistance with activities of daily living ( ADLs ), G Functional Status altered gait and balance, and decreased range of motion. Functional Abilities and -care and mobility activities. GG Assess the need for assistance with self Goals Gather information on the use of bowel and bladder appliances, the H Bladder and Bowel use of and response to urinary toileting programs, urinary and bow el , and bowel patterns. continence, bowel training programs to the resident’s current Code diseases that have a relationship I Active Diagnoses functional, cognitive, mood or behavior status, medical treatments, or risk of death. nursing monitoring, Document health conditions that impact the resident’s functional status J Health Condi ti ons and quality of life. Swallowing/Nutritional Assess conditions that could affect the resident’s ability to maintain K Status adequate nutrition and hydration. L Oral/Dental Status Record any oral or dental problems present . Document the risk, presence, appearance, and change of pressure M ulcers as well as other skin ulcers, wounds or lesions . Also includes Skin Conditions treatment categories related to skin injury or avoiding injury. Record the number of days that any type of injection, insulin, and/or N Medications select medications was received by the resident . Special Treatments , and programs that the Identify any special treatments, procedures, O Procedures and resident received during the specified time periods. Programs Record the frequency that the resident was restrained by any of the Restraints and Alarms P listed devices at any time during the day or night ; record the frequency that any of the listed alarms were used. Participation in Assessment Record the participation of the resident, family and/or significant others Q in the assessment, and to understand the resident’s overall goals. and Goal Setting Document triggered care areas, whether or not a care plan has been a Assessment Care Are developed for each triggered area, and the location of care area V (CAA) Summary assessment documentation. d already present in the QIES Request to modify or inactivate a recor X Correction Request . ASAP database Provide billing information and signatures of persons completing the Z Assessment Administration assessment. 14 October 2018 Page 1-

20 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) Protecting the Privacy of the MDS Data 1.8 personal in ent data is lity resi dents t hat f aci lities a re formation about nursing f MDS assessm aci ep con tial in accordance with fe deral law. The 42 CFR Part 483.20 ct and ke fiden olle required to c e and Medicaid ce rti fied n requir ing facil ity providers to c olle ct the re sident es M edicar urs hat com prises t he MDS. This data is consi dered p art of the resident ’s m edical assessm ent data t ted record pro per dis closure by Medic are and Med icaid ce rti fied facil ities by and is protec from im ease al formation from the re sident’ s cli nic ation at CFR 483.70(i) and 483.75(i)(4), rel regul of in nly red by: issible o when requi record is perm trans fer to another he 1. alth care institution, law (both St ate and Fed eral), and/or 2. the resident. 3. s ca Otherwise, provider lease MDS data in individual l evel format or in the ag grega te. nnot re aci lity providers are also re ans mit MDS data t o a Feder al Nursing f quired under CFR 483.20 to tr ta m l governm ained and ret rieved b y the Federa itory. Any personal da ent is su bje ct aint data repos ct of 1974. The Privacy Act speci fic ally prote cts the irements of the Privacy A to the requ fidentiali ty of perso nal ide ntif iable in formation and saf eguards ag ainst its m isuse. con Information regarding T he Privacy Act can be found at ms.gov/Resea - https://www.c rch cs-Da ta-and-Syst em s/C omputer- Dat a- and -Syste ms/Privacy/P rivac yActo f1974.html . Statisti Act requ The Privacy by regul ation that a ll in dividuals whose data are colle cted and ires in a f maintained atabas e mus t re ceive not ice. Therefore, residents in nursing fa ciliti es ederal d yste nal s e natio ed that t must be inform m, he MDS data is being col lected and subm itted to th Quality Improvem Assessm ent Su bmission and Pr ocessing S ystem (QIES stem ent Evaluation Sy this se ction m eets the The notice shown on page 1-16 of ASAP) and the State MDS database. vacy Act of 1974 for nursing f aci lities. The form is a noti ce and not a requirements of the Pri lease or use are in formation. Each re sident or fam ily mem ber MDS data for health c consent to re ission. It is ning submission inform ation at the tim e of adm must be given the not ice contai important to re mem ber that resident consent is not req uired to co mplete and subm it MDS RA ’87) or assessm equired unde r O mnibus Budget Reconc ilia tion Act of 1987 (OB re r ents that a for Medic are pay ment purposes. Contractual Agreements ffice or ho are p art of a m ulti-fac ili ty corp ora tion m ay re lease d ata to thei r corp orate o Providers w orporation. The parent parent c ompany but not to other provider s wi thin the multi-f aci lity c acility and is perm itted to u company is required to “ act” in the same m anner as the f nly se data o mitted to do so (as descri to the ex aci lity is per the f bed in 42 CFR a t 483.10(h)(3)(i) ). tent h its throug e where a f aci lity sub mits MDS data to CMS through a contrac tor or as In the c corpora te o ffice, the co ntra ctor or c orporat e o ffice has the sa me rights and res trictio ns as the ity does facil la tions with res under the F eder al and S tate regu pect to m aintai ning re sident dat a, keeping su fidenti al, and making disclosures of such data. Th is m eans that a cont ract or ch data con may m ainta in a datab ase, but must abide by the same rules and regula tio ns as the facil ity. Moreover, t he f act th at t here m ay have been a change of ownership of a f aci lity that has been ies; sponsibilit trans fer ring data t hrough a cont ract or should not alt er the co ntra ctor' s rig hts and re 15 October 2018 Page 1-

21 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) presu mably ding ctu al rig hts and obligations, inclu , the new owner has assumed existing contra agreements, regardless ual those under the con tract f or su bm itting MDS information. All cont ract cipation in the pe, involving the MDS data should not viola te the requirem ents of parti of their ty aid program, the Privacy Medica re and/or Medic Act of 1974 or any applicable S tate l aws. HEALTH CARE RECORDS PRIVACY ACT STATEMENT – Long Term Care-Minimum Data Set (MDS) System of Records revised 04/28/2007 -6-12, Implementation/Effective Date: 6-17-13) (Issued: 9 THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1974 (5 USC 552a). THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU. 1. AUTHORITY FOR COLLECTION OF INFORMATION, INCLUDING SOCIAL SECURITY NUMBER AND WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY. Authority for maintenance of the system is given under Sections 1102(a), 1819(b)(3)(A), 1819(f), 1919(b)(3)(A), 1919(f) and 1864 of the Social Security Act. The system contains information on all residents of long- term care (LTC) facilities that are Medicare and/or Medicaid certified, including private pay individuals and not limited to Medicare enrollment and entitlement, and Medicare Secondary Payer data containing other party liability insurance information necessary for appropriate Medicare claim payment. Medicare and Medicaid participating LTC facilitie s are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. To implement this requirement, the facility must obtain information from every is also used by the Centers for Medicare & Medicaid Services resident. This information (CMS) to ensure that the facility meets quality standards and provides appropriate care to all residents. 42 CFR §483.20, requires LTC facilities to establish a database, the Minimum Data Set (M DS), of re sident assessment information. The MDS data are required to be electronically transmitted to the CMS National Repository. Because the law requires disclosure of this information to Federal and State sources as discussed above, a resident does not have the right to refuse consent to these disclosures. These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS LTC System of Records. 2. PRINCIPAL PURPOSES OF THE SYSTEM FOR WHICH INFORMATION IS The primary purpose of the system is to aid in the INTENDED TO BE USED. administration of the survey and certification, and payment of Medicare/Medicaid LTC - services which include skilled nursing facilities (SNFs), nursing facilities (NFs) and non critical access hospitals with a swing bed agreement. Information in this system is also used to study and improve the effectiveness and quality of care given in these facilities. This system will only collect the minimum amount of personal data necessary to achieve the purposes of the MDS, reimbursement, policy and research functions. October 2018 Page 1- 16

22 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) The information ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM. 3. collected will be entered into the LTC MDS System of Records, System No. 09-70-0528. This system will only disclose the minimum amount of personal data necessary to accomplish t he purposes of the disclosure. Information from this system may be disclosed to the following entities under specific circumstances (routine uses), which include: To support Agency contractors, consultants, or grantees who have been contracted by (1) the Agency to assist in accomplishment of a CMS function relating to the purposes for this system and who need to have access to the records in order to assist CMS; To assist another Federal or state agency, (2) agency of a state government, an agency established by state law, or its fiscal agent for purposes of contributing to the accuracy of CMS’ proper payment of Medicare benefits and to enable such agencies to fulfill a ulation that implements a health benefits requirement of a Federal statute or reg program funded in whole or in part with Federal funds and for the purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State, and determine Medicare and/or Medicaid eligibility; To assist Quality Improvement Organizations (QIOs) in connection with review of (3) claims, or in connection with studies or other review activities, conducted pursuant to of the Social Security Act and in performing affirmative Title XI or Title XVIII outreach activities to individuals for the purpose of establishing and maintaining their entitlement to Medicare benefits or health insurance plans; To assist insurers and other entities or organizations that process individual insurance (4) claims or oversees administration of health care services for coordination of benefits with the Medicare program and for evaluating and monitoring Medicare claims information of beneficiaries including proper reimbursement for services provided; (5) To support an individual or organization to facilitate research, evaluation, or epidemiological projects related to effectiveness, quality of care, prevention of disease or disability, the restoration or maintenance of health, or payment related projects; To support litigation involving the agency, this information may be disclosed to The (6) Department of Justice, courts or adjudicatory bodies; (7) ties meet certain To support a national accrediting organization whose accredited facili Medicare requirements for inpatient hospital (including swing beds) services; To assist a CMS contractor (including but not limited to fiscal intermediaries and (8) benefits -administered health carriers) that assists in the administration of a CMS program, or to a grantee of a CMS-administered grant program to combat fraud, waste and abuse in certain health benefit programs; and October 2018 Page 1- 17

23 CMS’s RAI Version 3.0 Manual CH 1: Resident Assessment Instrument (RAI) To assist another Federal agency or to an instrumentality of any governmental (9) jurisdiction within or under the control of the United States (including any state or local governmental agency), that administers, or that has the authority to investigate potential fraud, waste and abuse in a health benefits program funded in whole or in part by Federal funds. 4. EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION. The information contained in the LTC MDS System of Records is generally necessary for the facility to provide appropriate and effective care to each resident. If a resident fails to provide such information, e.g. thorough medical history, inappropriate and potentially harmful care may result. Moreover, payment for services by Medicare, Medicaid and third parties, may not be available unless the facility has sufficient information ual and support a claim for payment. to identify the individ NOTE: Residents or their representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions, or distributed in other ways to residents or their representative(s). Although signature of receipt is NOT required, providers may request to have the Resident or his or her Representative sign a copy of this notice as a means to document that notice was provided and merely acknowledges that th ey have been provided with this information. Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of this form will be furnished to you. ______________________ ___________________________________________ Date ature of Resident or Sponsor Sign ive sign Providers m ay request to ha ve the Resi dent or his or her Represe ntat NOTE: a copy of this not ice a s a means to document that not ice was provided. Signatu re is NOT required. If the they r Representa tive agrees to sign the f orm it m erely acknowledges that Resident or his or he have been advised of the foregoing information. Residents or thei r Repre sentat ive must be or a ith a copy of the notice. This noti supplied w ay be in ll cluded in the admission packet f ce m issions. new nurs ing hom e a dm Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program have granted permission to use these instruments in , LLC association with the MDS 3.0. 18 Page 1- October 2018

24 CMS’s RAI Version 3. CH 0 Manual 2: Assessments for the RAI CHA PTER 2: ASSESSMENTS FOR THE RESIDENT ASSESSMENT INSTRUMEN T (RAI) This chapter presents the assessment types and instructions for the completion (including timing and scheduling) of the mandated OBRA and Medicare assessments in nursing homes and the mandated Medicare assessments in non ing bed agreement. -critical access hospitals with a sw 2.1 Introduction to the Requirements for the RAI The statutory authority for the RAI is found in Section 1819(f)(6)(A -B) for Medicare, and 1919 (f)(6)(A -B) for Medicaid, of the Social Security Act (SSA), as amended by the Omnibus Budge t Reconciliation Act of 1987 (OBRA 1987). These sections of the SSA require the Secretary of the Department of Health and Human Services (the Secretary) to specify a Minimum Data Set (MDS) of core elements for use in conducting assessments of nursing home residents. It furthermore requires the Secretary to designate one or more resident assessment instruments based on the MDS. The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or assessments for all their residents. The Resident Assessment both, to conduct initial and periodic Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS. The OBRA -required assessments will be d escribed in detail in Section 2.6. MDS assessments are also required for Medicare payment (Prospective Payment System [PPS]) purposes under Medicare Part A (described in detail in Section 2.9) or for the SNF QRP required under the Improving Medicare Post -Acute Care Transformation Act of 2014 ( IMPACT Act ). assessment time frames coincide, It is important to note that when the OBRA and Medicare PPS one assessment may be used to satisfy both requirements. In such cases, the most stringent completion must be met. Therefore, it is imperative that nursing home staff requirement for MDS fully understand the requirements for both types of assessments in order to avoid unnecessary duplication of effort and to remain in compliance with both OBRA and Medicare PPS req uirements. (Refer to Sections 2.11 and 2.12 for combining OBRA and Medicare assessments). 2.2 CMS Designation of the RAI for Nursing Homes Federal regulatory requirements at 42 CFR 483.20(b)(1) and 483.20(c) require facilities to use an RAI that has been specified by CMS. The Federal requirement also mandates facilities to encode and electronically transmit the MDS data. (Detailed submission requirements are located in Chapter 5.) While states must use all Federally required MDS 3.0 items, they have some flexibility in adding optional Section S items. Page 2- October 2018 1

25 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual • CMS’ specified RAI covers the core items included on the instrument, the wording and ing of those items, and all definitions and instructions for the RAI . sequenc CMS’ specified RAI does not include characteristics related to formatting (e.g., print type, • color coding, or changes such as printing triggers on the assessment form) . must include at least the CMS MDS Version • All comprehensi ve RAIs specified by CMS 3.0 (with or without optional Section S) and use of the Care Area Assessment (CAA) . process (including CATs and the CAA Summary (Section V)) • If allowed by the State, facilities may have so me flexibility in form design (e.g., print type, color, shading, integrating triggers) or use a computer generated printout of the RAI as long as the State can ensure that the facility’s RAI in the resident’s record accurately and completely represents the CMS -specified RAI in accordance with 42 CFR 483.20(b). This applies to either pre -printed forms or computer generated printouts . • Facility assessment systems must always be based on the MDS (i.e., both item terminology and definitions). However, facilities may insert additional items within automated assessment programs, but must be able to “extract” and print the MDS in a manner tha specified RAI (i.e., using the exact wording and sequencing t replicates CMS’ of items as is found on the RAI ). specified by CMS Additional information about CMS specification of the RAI and variations in format can be found in Sections 4145.1–4145.7 of t he CMS State Operations Manual (SOM). For more information about your State’s assessment requirements, contact your State RAI coordinator (see Appendix B) . 2.3 Responsibilities of Nursing Homes for Completing Assessments The requirements for the RAI are f ound at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long -term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source. Federal RAI certified units of long -term care requirement s are not applicable to individuals residing in non- -only facilities. This does not preclude a State from mandating the RAI for facilities or licensed residents who live in these units. Please contact your State RAI Coordinator for State requirements. An RAI (MDS, CAA process, and Utilization Guidelines) must be completed for any resident residing in the facility, including: • All residents of Medicare (Title 18) skilled nursing facilities (SNFs) or Medicaid (Title 19) nursing facilities (NFs). This includes certified SNFs or NFs in hospitals, regardless of payment source. When a SNF or NF is the hospice patient’s residenc e for purposes of • Hospice Residents: the hospice benefit, the facility must comply with the Medicare or Medicaid participation requirements, meaning the resident must be assessed using the RAI, have a care plan and e. This can be achieved be provided with the services required under the plan of car Page 2- October 2018 2

26 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual through cooperation of both the hospice and long -term care facility staff (including participation in completing the RAI and care planning) with the consent of the resident. Short -term or respite residents: • An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long -term care facility for participation in the Medicare or Medicaid programs. If the respite resident is in a certified bed, the OBRA assessment schedule and tr acking document requirements must be followed. If the respite resident is in the facility for fewer than 14 days, an OBRA Admission assessment is not required; however, a Discharge assessment is n OBRA required: — Given the nature of a short -term or respite resident, staff members may not have access to all information required to complete some MDS items prior to the resident’s discharge. In that case, the “not assessed/no information” coding convention should be used (“ - ”) (See Chapter 3 for more information ). — Regardless of the resident’s length of stay, the facility must still have a process in place to identify the resident’s needs, and must initiate a plan of care to meet those needs upon admission. — If the resident is eligible for Medicare Part A benefits, a Medicare assessment will still be required to support payment under the SNF PPS. • Special population residents (e.g. pediatric or residents with a psychiatric diagnosis): Certified facilities are required to complete an RAI for all residents who e in the facility, regardless of age or diagnosis. resid • Swing beds of non- critical access hospitals that provide Swing bed facility residents: Part A skilled nursing facility -level services were phased into the SNF PPS on July 1, 2002 (referred to as swing beds in this manual). Swing bed providers must assess the clinical condition of beneficiaries by completing the MDS assessment for each Medicare resident receiving Part A SNF level of care in order to be reimbursed under the SNF PPS. CMS collects MDS data for quality monitoring purposes of swing bed facilities effective October 1, 2010. Therefore, swing bed providers must also complete the Entry record, PPS a ssessments, Discharge assessments, and Death in Facility record. Requirements for the Medicare- required PPS assessments, Entry record, Discharge assessments and Death in Facility record outlined in this manual also apply to swing bed facilities, including but not limited to, completion date, encoding requirements, submission time frame, and RN signature. There is no longer a separate swing bed MDS assessment manual. The IMPACT Act of 2014 established Skilled Nursing Facility Quality Reporting Program: the Skilled Nursing Facilit y Quality Reporting Program (SNF QRP). Amending Section 1888(e) killed nursing f acilities are to collect of the Social Security Act, the IMPACT Act mandates that s and report on standardized patient assessment data. Failure to report such data results in a 2 percent reduction in the SNF’s market basket percentage for the applicable fiscal year. • Section GG: Functional Abilities and Goals assesses the need for assistance with self -care and mobility activities; it is collected at the start of a Medicare Part A stay on the 5 -Day PPS assessment and is also collected at the end of the Medicare Part A stay on the Part A PPS Discharge assessment. Section GG was added to the MDS 3.0 in order to be able to -based quality me collect the data required to calculate t he functional status process asure, Page 2- October 2018 3

27 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual Application of the Percent of Long- Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631 ). An adapted version of this LTCH measure was finalized for skilled nursing facilities in Y 2018 payment determination. Data the Fiscal Year (FY) 2016 SNF PPS final rule for F collected for the SNF QRP is submi through the QIES ASAP system as it currently is tted for other MDS assessments. It is important to note that data collection for Section GG do es not substitute for the data collect ed in Section G because of the difference in rating scales, item definitions, and type of data collected. Therefore , providers are required to collect data for both Section . GG and Section G Additional information regarding the measures may IMPACT Act and associated quality be found on CMS’s website at: https://www.cms.gov/Medicare/Quality -Initiatives - Patient -Assessment -Instruments/Post -Acute- Care- Quality -Initiatives/IMPACT -Act -of- -Setting -Cross . -Measures.html 2014/IMPACT -Act -of-2014- Data- Standardization -and must be used with res idents in facilities with different certification The RAI process situations, including: • Newly Certified Nursing Homes: — Nursing homes must admit residents and operate in compliance with certification requirements before a certification survey can be conducted. — Nursing homes must meet specific requirements, 42 Code of Federal Regulations, Part 483 (Requirements for States and Long Term Care Facilities, Subpart B), in order to participate in the Medicare and/or Medicaid programs. The completion and submission of OBRA and/ or PPS assessments are a requirement — -term care facilities. However, even though OBRA for Medicare and/or Medicaid long does not apply until the provider is certified, facilities are required to conduct and complete resident assessments prior to certification as if the beds were already .* certified — Prior to certification, although the facility is conducting and completing assessments, these assessments are not technically OBRA required, but are required to demonstrate compliance with certification requiremen ts. Since the data on these pre- certification assessments was collected and completed with an ARD/target date prior to the certification date of the facility, CMS does not have the authority to receive this into QIES ASAP. Therefore, these assessments cann ot be submitted to the QIES ASAP system. — Assuming a survey is completed where the nursing home has been determined to be in substantial compliance, the facility will be certified effective the last day of the survey and can begin to submit OBRA and PPS re quired assessments to QIES ASAP. o For OBRA assessments, the assessment schedule is determined from the resident’s actual date of admission. Please note, if a facility completes an Admission assessment prior to the certification date, there is no need to do another Admission assessment. The facility will simply continue with the next expected assessment according to the OBRA schedule, using the actual admission Page 2- October 2018 4

28 CMS’s RAI Version 3. 2: Assessments for the RAI 0 Manual CH date as Day 1. Since the first assessment submitted will not be an Entry or OBRA ischarge, etc., the facility may Admission assessme nt, but a Q uarterly, OBRA D receive a sequencing warning message, but should still submit the required assessment. o For PPS assessments, please note that Medicare cannot be billed for any care provided prior to the certifica tion date. Therefore, the facility must use the certification date as Day 1 of the covered Part A stay when establishing the Assessment Reference Date (ARD) for the Medicare Part A SNF PPS assessments. *NOTE: Even in situations where the facility’s certification date is delayed due to the — need for a resurvey, the facility must continue conducting and completing resident assessments according to the original schedule. • Adding Certified Beds: — If the nursi ng home is already certified and is just adding additional certified beds, the procedure for changing the number of certified beds is different from that of the initial certification. — Medicare and Medicaid residents should not be placed in a bed until the facility has been notified that the bed has been certified. • Change In Ownership: There are two types of change in ownership transactions: — The more common situation requires the new owner to assume the assets and liabilities of the prior owner. In this c ase: The assessment schedule for existing residents continues, and the facility ○ continues to use the existing provider number. ○ Staff with QIES user ID s continue to use the same QIES user IDs. Example: ○ if the Admission assessment was done 10 days prior to the change in ownership, the next OBRA assessment would be due no later than 92 days after the ARD (A2300) of the Admission assessment, and would be submitted using the existing provider number. If the resident is in a Part A stay, and the 14 -Day Medicare PPS assessment was combined with the OBRA Admission assessment, -Day MDS, the next regularly scheduled Medicare assessment would be the 30 and would also be submitted under the existing provider number. — There are also situations where the new owner does n ot assume the assets and liabilities of the previous owner. In these cases: ○ The beds are no longer certified. ○ There are no links to the prior provider, including sanctions, deficiencies, resident assessments, Quality Measures, debts, provider number, etc . ○ The previous owner would com plete an OBRA Dischar ge assessm ent - return n ot anti cipa ted, thus code A 0310F = 10, A2000 = date of ownership change, a nd main in the f lity. aci A2100 = 02 for those res idents who will re Page 2- October 2018 5

29 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual ○ wner would complete an A dm ission assessm ent and Entry t racking The new o l re ts, t hus code A0310F=01, A1600=date of ownership change, or al record f siden ission), a nd A1800=02. A1700=1 (a dm Staff who worked for the previous owner cannot use their previous QIES user ○ IDs to submit assessments for the new owner as this is now a new facility. They must register for new user IDs for the new facility. Com pliance with OBRA regul ations, inclu ○ he MDS requirem ents, is ding t expected he ti me of s urvey f or c erti fication of the f aci lity with a new owner. at t formation above es. wly cer tified nursing hom See in r egarding ne • Resident Transfers: When trans ferring — esident, the tr ansferring f acili ty m ust provide the ne w f acility a r with neces sary m edical r ecords, i ncl uding appropri ate MDS assessm ents, to support the cont inuit resident care. y of whether or n dm itting a resi dent f rom ano ther nur sing h om e, rega rdless of — ot i t When a rans is a t ame chain, a new A dm ission asse ssment m ust be done within fer within the s arts with the new A dm ission asse ssment and, if 14 days. The MDS schedule then st appli cable, a 5- day Med icar e-req uir ed PPS assessm ent. us — mitting f acil ity s hould look a t the previo The ad facil ity’s a ssessm ent in the sa me way they would r eview oth er inco ming docum entation about the r esident f or t he purpose of understandi ng the re sident’s h istory and prom oting continui ty of care. However, the ent f ission assessm pose of or the pur admitting f aci lity m ust per form a n ew A dm planning c are within ity to which the re sident has been trans ferred. that facil When there esult of rans fer of re sidents as a r a n atur al dis aster(s) (e.g., has been a t — ith an an ticipated retu rn to the f acility, t he evac uating ire) w flood, earthquake, f ity sho fice, Stat act t heir Regio nal Of facil e agency, and Medic are contr actor uld cont for guidanc e. aster(s) (e.g., f has been a t rans fer as a r esult of a n atur al dis — lood, When there uake, f ire) and it has been d etermined that t he resi dent will not ret urn to t he earthq evacuat ing f aci lity, the e vacuat ing p rovider w ill d ischar ge the resident r eturn not ecei anticipa ted and the r ving f aci lity will ad mit the resi dent, w ith the MDS cycle beginning a s of mission da te to the r ecei vi ng f acil ity. For ques tions rel ated to the ad fice, Stat pe of ation, pr oviders should cont act t heir Regio nal Of this ty e agency, situ and Medi care cont ract or f or guidanc e. — More in for mation on e mergency preparedn ess c an be f ound at: http ms.gov/Medica re/Pro vider -Enr ollm ent -and- ://www.c Certi ficatio n/SurveyCe rtEmergPrep/ index.ht ml . 2.4 Responsibilities of Nursing Homes for Reproducing and Maintaining Assessments The Federal regul atory aintain all ment at 42 CFR 483.20(d) re quires n ursi ng h om es to m r equire sident’s a nical cli ctive resident as sessm ents co mpleted wi thin the prev ious 15 m ont hs in the re Page 2- October 2018 6

30 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual record. T rement appli es to a ll MDS assess ment types regard less of the f orm of storage his requi rd c lectronic or ha opy). (i.e., e The 15- month pe riod f or maintai ning assessm • ay not re start with each ent data m mission to the f aci lity: read When a res ident is d ischarged retu — ed and the r esident retu rns to the rn anticipat fac within 30 days , the f acil ity m ust copy t he previous RAI and t rans fer th at ility new record. rement f mont h requi copy to the or m aintenance of t he RAI data The15- hered to. must be ad When a res ident is — ischarged retu rn anticipat ed and does not return w ithin 30 d days or dis charged ret urn not anti cipated , f aci lities m ay develop the ir own speci fic poli cies r handle r etu rn situ ations, whether or not to copy t he egarding how to he new record. previous RAI to t In cases wh ere the re sident r eturns to the f aci lity af ter a long break in care (i.e., 15 — months or l onger), s ay want to review t he older r ecord and f amilia rize taff m mselves with the res ident hi story and care ne eds. However, the de cisi on on the ret aining the prior s tay re cord in the a ctive cli nic al record is a m atter of f acility po licy and is not a CMS requi rement. rom 5- month period, RAI inf ormation • ay be thinned f After the 1 the clin ical r ecord a nd m stored in the m edical r ecords depa rtment, provided that it is e asily re trie vable if req uested by cli nical s taff, State agency surve yors, CMS, or othe rs as a uthor ized by law. The rom A1600) f most recent the exception is that de mographic inf or mation (It ems A0500- Adm ission assessm must be m aintained in the acti ve cl ini cal r ecord unt il t he res ident ent harg anti cipa ted or is discharged return anticipated but does not return is disc ed return not within 30 days . Nursing hom es m ay u se elec tro • signat ures f or c linic al record docum entat ion, including nic the MDS, when per mitted t o do so by State and loc al law and when author ized by the facil ity’s p olic y. Use of ele ctron ic sign atures f or the MDS does not requi re th at t he ent ire clinical record aintained elec tro nically. F acilities m ust have writ ten pol icies in place be m oper secur ity measures are in place to prote ct the use of an elec tron ic to ensure pr signature by a nyone other than the per son to whom the el ect ron ic sign ature belongs. or a resi • Nursing hom es also have the op tion f dent’s c linic al record to be m aintain ed icall elec tron y rath er than in hard cop y. This also appli es to portions of the cli nical record such as the MDS. Main t he MDS elect ronic ally d oes not req ui re that the entir e tenance of record also be m se of ained e lectro nical ly, nor does i t r equire the u cli nical elect ronic aint ures. signat tron ere the MDS is m aintain • In cases wh ically w ithout the use of e lectro nic ed elec signat ures, nursing hom es m ust maintain, at a m ini mum , hard copies of si gned and dat ed CAA(s) co Items V0200 B-C), correction com ple tion ( Items X1100A -E), and mpletion ( assessm ent co mpletion ( Ite ms Z0400- Z0500) da ta that is r esident -iden tifiable in the resident’s linic al record. a ctive c • Nursing hom lity ust ensure tha t pr oper secur ity measures ar e implemented via f aci es m the egrity of r ecord. policy to en sure the priv acy and int Page 2- October 2018 7

31 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual • es m ust a lso ensure t hat cl ini cal r ecords, re gardless of f orm, are m aintained Nursing hom ation licy and pr ed by facil ity po alized loc ocedure (e.g., a f acil ity wi th as deem in a centr aintain all recor ds i n one loc ation or by uni t or a f acility m ay maintain ay m five units m sess ments and care plans in a sep arate binder). N the MDS as es m ust also ursing hom ensure t lin ical reco rds, regar dle ss of f or m, are eas ily and read ily ac cessible to s taff hat c cluding c nts), (in State agenci es (in cludi ng surveyor s), CMS, and others who a re onsulta formation in order author ed to re view the in y law and ne to provi de c are to the ized b resident. Resident specific information must also be available to the individual resident. • es that are not capable of m aintenance of the M DS electro nically m ust Nursing hom he cur or equire ment th at either a ha ndwrit ten adhere to t a co mputer -gen erated copy rent r be m aintained in the inical record for 15 months following the final completion active cl This date for all assessments and correction requests. ll MDS records, including i ncludes a the CAA Summary, Quarterly assessment records, Identification Information, Entry and Death in Facility Tracking records and MDS Correction Requests (including signed attestation). • All Sta te licensure and S tate pra ctic e regul ations continue to apply to Me dicar e and/ or s m Medica f acil ities. W here State law i erti fied ore restr ictive than Federal id c req uire ments, t he provide r needs to ap ply the St ate l aw standard. to a C • In the f uture , f acilitie s m ay be required to conf orm MS elec tro nic signat ure standard shoul d CMS adopt one. 2.5 Assessment Types and Definitions sse e residents, it nursing hom ssments of In order to understand t he requ irements f or conducting a is f irst nt to unde rstand som e of the conc epts and de finitions ass ociat ed with MDS i mporta ents. Concepts a or asses finitions f assessm sments are only in troduc ed in this se ction. nd de Detai struc tions a re provided th roughout the rest of t his c hapter. led in Admi ssio n refers to t he date a pe rson ente rs the f acil ity a nd is ad mitte d as a res ident. A day whether begins a . and ends at 1 1: 59 p.m . Regardless of 00 a.m ad mission occurs at 12:00 t 12: st ., this date i s cons idered t he 1 a dm day of a.m. or 11:59 p.m ission. Com ple tion of an OB RA the f Adm ent must occur in any of ission assessm ollowing ad mission s ituat ions: • itted to th when the re sident ha s n ever been adm is facil ity be fore; OR • sident ha s b een in t his f aci lity p revi ously and w as disch arged return not when the re cipa OR anti ted; lity p sident ha s b • his f aci when the re revi ously and w as disch arged return een in t anti cipa ted a nd did not re turn wit hin 30 days of dischar ge ( see Dischar ge assessm ent below). Asses en t Combi nat ion refers to t sm one asses sment to sat isfy both O BRA and he use of Medica re P PS assessm ent req uire ments when the ti me f rames coinci de f or both requir ed re assessm ses, the m ost strin gent ents. In such ca quire ment of the two ass essments f or MDS om ing h aff fully understand the e st completion m ust be m et. There fore, it is i mperat ive that n urs Page 2- October 2018 8

32 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual requi ypes of asses sments in order to avoid unnecess ary duplic ation of ef fort rements f or both t mpliance with bot re PPS requir RA and Medica main in co ements. Sections 2.11 and to re h OB re and ore detai ovide m om bining M edica led in OB RA assess ments. In and 2.12 pr for mation on c tion, when all requ irements f or both are m et, one assess ment m ay sat addi BRA isfy two O assessm equire ment s, such as Adm ission and OBRA Discharge a ssess ment, or two PPS ent r ents, such as a 3 essment and an End of Therapy OMRA. assessm 0- day ass on refers t o the da te t hat al l in for mation needed has been Assessmen t Completi ected and coll record or a par ticular asses ed f ff have signed and dated t hat t he assessment is sment type and sta complete. • -required C om prehensive assessm ents, assess ment co mpletion is de fined as For OBRA the in a ddition to t he MDS ite ms, m eaning that the RN completion of CAA process ent coordina tor has signed a nd dated bot h the MDS ( assessm Z0500) and CAA(s) Item (Item 00B) co mpletion a ttes tations. Since a V02 prehensive ass essm ent in cludes C om completion of both the MDS and the CAA process, the a sse ssm ent tim ing requi rements for a co sessm ent apply to both t he co mpletion of the MDS and the CAA mprehensive as process. • For non- com prehensive and Discha rge assess ments, ass essm ent co mplet ion is de fined as ator has s completion of DS only, m eaning that the RN assessm ent coor din the M ign ed and dated t he M DS (Item Z 0500) com pletion a ttestation. ming requi ment type and ti a ssess rements. Com pletion requi rements are depen dent on the Com pletion assessm ent t ype are dis cussed in Se ction 2.6 f or OB RA assess ments and speci fics by care assessm ents. Section 2.9 f or Medi Date (ARD) ce refers to the la st day of the observa tion ( or “look Assessmen t Referen eriod that the as sessm ent covers f or the reside nt. Si nce a day be gins at 1 2:00 a. m. and back”) p 1: 59 p.m m ends at 1 ust also cover th is ti me peri od. The f acil ity is r equ ired to set the ., the ARD MDS Item lity so in the f aci ARD on the ftware wit hin t he requ ired tim eframe of the Set or RD is used f assessm pleted. Thi s concept of set ting the A ype being com or a ll asse ssm ent ent t types (OBRA and Med icar e-req uir ed PPS) and varies by as sess ment type and f aci lity deter mination. Most of the ems have a 7 day look ba ck period. If a resi dent h as an MDS 3.0 it th and e nding on or mation s tarting at 12 AM on June 25 rtine 2011 then a nt inf ll pe ARD of July 1, st uded f at 11:59PM s hould be incl or MDS 3.0 coding. 1 July refers t o the pe riod of Assessmen t Scheduling e during which a ssessm ents t ake place, tim set ting the A RD, t iming, com pletion, subm ission, and the obs erva tion pe riods requi red to complete the MDS ite ms. ic MDS data being in mi refers t o elec Assessmen t Sub ssion reco rd and f ile f ormats that tron con for m to standard rec ord layo uts a nd data di ctionaries, and passes s tan dardi zed ed its de fined by CMS and the St ate. Chapter 5, C FR 483.20( f)(2), and the MDS 3.0 D ata Sub mission formation. led in ore detai ions on the CMS MDS 3.0 web site provide m Speci ficat Page 2- October 2018 9

33 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual Assessmen t Timi hen and how of ten asses sments m ust be conduct ed, based ng refers to w t’s len e bet stay and the len gth of tim siden ween ARDs. The table in Section 2.6 upon the re gth of -requi bes t ing sc hedule f or OBRA ment tim red assess ments, while i nfor mation on descri he assess e-req uired P PS assessm ent tim ing s chedule i s p the Medicar ection 2.8. rovided in S • For OBRA -required ass essm ents, regulat ory req uire ments f or each as sessment type ate as ch is es ing, the sche dule f or whi dict tablished with the A dmission sessment tim and mprehensive) a ment when t (co assessm ent coordina tor ssess he ARD is set by the RN the I nter dis ciplinary t eam (IDT). • Ass um ing the resi dent di d not expe rience a s igni ficant change in st atus, was not dischar ged, have a Sign ificant Corr ection to Pri or C om prehensive as sessm ent and did not mpleted, as cycle of ment scheduling would then move through a (SCPA) co th ree sess prehens ly a Quarter llowed by an Annual ( com ssessm ive) ass essm ent. ents fo • This cyc le ( Com prehensive ass essm ent – Quar terly as sess ment – Quart erly assessm ent – elf annually f Quarter ent – C om prehensive ass essm ent) would r epeat its ssessm or t he ly a resident who: 1) t he IDT deter mines the c riteria f or a Signi ficant Change in Status Assessm ent (SCSA) has not occur red, 2) an uncor rect ed sig ni ficant err or i n prior harg comprehensive or Quar sess ment was not d eter mined, a nd 3) was not disc terly as ed with r eturn not ant icip ated. led early es tagger due dat e wants to s if a nursing hom • OB RA assessm ents m ay be schedu for assessm ents. As a res ore th an three OBRA Quarterly assessm ents may be ult, m ay be c ticu in a given ye ar, or the Annual m sident om pleted ea rly completed on a par lar re th at reg ulat ory to ensure e f ram es between as sess ments are m et. How ever, St ates m ay tim have m ore stringe nt re strictions. • When a res ident does ha ve a SCSA or SCPA c om pleted, the assessm ent reset s the assessm ent t terly assessm ent would be s cheduled w ithin iming/scheduling. The next Quar 92 days a the SCSA or SCPA, a nd the next com prehens ive assess ment fter the ARD of would be s cheduled wi thin 366 days after the ARD of the S CSA or SC PA. assessm • Early Me di care -requ ired ents co mpleted with an ARD prior to t he beginning of ave a pay the pre scribed ARD wi ndow will h lty a ment pena pplied (see S ection 2.13). Assessmen t Tran sm ref ers to the e lectro nic t rans mission of sub mission files to the ission QIES ent Su bm ission and Proces sing Quality Improvement Evaluation System ( ) Assessm em using the Medica re D ata C ommunication Networ k (MDCN). Chapter 5 a nd the (ASAP) syst eb site provi CMS MDS 3.0 w ore detai led in formation. de m hen si ve Compre ents in clude both the co mpletion of the MDS as well as MDS assessm completion of the Care Area Asses sment (C AA) process and care plann ing. C om prehensive MDSs incl ude A ission, Annual, Signi ficant Change in St atus Assessm ent (SCSA), and dm ficant Signi tion t o Prior Co mprehensi ve Assessm ent (SCPA). Correc Deat h In Facili ty refers to when the re side nt dies in the f aci lity or di es while on a leave of absence (LOA) (see LOA de finitio n). The f aci lity must co mplete a Deat h in Fac ility tracking uired. ent is req essm D ischarge ass record. No 10 October 2018 Page 2-

34 CMS’s RAI Version 3. 0 Manual CH 2: Assessments for the RAI Discha the date a resi dent l eaves t he facil ity or the date the resident’s Medicare rg e refers to t 12:00 a.m . and ends at Part A stay ends but the resident remains in the facility . A day begins a ., this whether dischar ccurs at 1 11:59 p.m m. or 11:59 p.m ge o date i s of . Regardless 2: 00 a. he actu al da te of discha rge. There ar e three types of discharg es: two are OBRA conside red t urn a ipated and ret —ret urn not an ticip ated; the third is Medicare required —Part A required ntic rge assess charges. Section equ ired with all three t ypes of dis . A Discha PPS Discharge ment is r , ins egar ding return anticipated and return not anticipated ty pes ailed 2.6 provides det tructions r . Any of and Section 2.8 provides detailed instructions regarding the Part A PPS Discharge type situ ations w arrant a Dis charge as sessment , regardless of the following lity pol icies r egarding f aci opening and closing nical r ecords a nd bed holds : cli te resi ischarged f rom the f acil ity to a p riva s d dence ( as opposed t o going on a n • Resident i LOA); Resident i s a dm itted to a hospit al or other c are s etting (re gar dless of whether the nursi ng • hom e disch ormally c loses t he record); arges or f he a hospi tal o bservat ion s tay grea ter t han 24 hours, r • less of whether t Resident has egard hospit its the res ident. al adm • and/or Medicaid -certified bed to a noncertified Resident is transferred from a Medicare- bed. stay Resident’s Medicare Part A • ends, but the resident remains in the facility. Discha rg e Assessmen to an assess ment req uired on reside nt d ischarge from the t refers . s in the facility facility, or when a resident’s Medicare Part A stay ends, but the resident remain ncludes c lini cal i tems f or qual ity m This assessm ring as w ell a s disc harge t racking ent i onito information. ry is a t erm used f or both an a dm ission and a ree ntry, a nd requi res c om pletion of an Entry Ent ecord. tracking r ents and tracking r d Discha rti ng MDS a ry an rge Repo ecords t hat i nclude a Ent ssessm t num ber of ite ms from the M DS used to t rack resi dents and gath er im portant qual ity data at selec tran sition po ints, such as when they e nter a nursing home , lea ve a nursing hom e, or when a resident’s Medicare Part A stay end s, but the resident r s in the facility . Entry /Discharge emain s En Disc acking r ecord, OBRA reporting include harge as sessments, Part A PPS Discharge try tr h in Fa cili ty t racki ng record. assessment, and Deat 1 na ry Te am (ID T professional disciplines th ) is a g roup of Int er discipli at co mbine knowledge, ski ources to pr ovide the greatest benefit to the res ide nt. lls, and res 1 42 CFR 483.21(b)(2) A c omprehensive ca re plan must be (ii) Prepared by an interdisciplinary team, that includes but is not limited to - the atte nding physician, a registered nurse with responsibility f or the res ident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate s taff or s or as requested by the resident, professionals in disciplin es as determi ned by the resident’s need and, to the extent practicab n of the resident and the resident’s representative(s). le, the partic ipatio 11 October 2018 Page 2-

35 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual Item he MDS ite ms that a re act ive on a pa rtic ular as sessm ent type or t racking Set refers to t 8 f ffe tem subsets f or nur sing hom es and di or swing bed provi ders as for m. There are 11 rent i follows: Nursing Home • 2 — C Comprehensive (N Th set of items active on an OBRA ) Item Set. is is the prehensive ass essm ent (Ad mission, Annual, Signi ficant Change in Status, and Com ve Assessm ficant tion of Prior C om prehensi Correc ents). This i tem set is used Signi whether t he OB RA C omprehensi ve a ssessm ent is stand -alone or co mbined with any other a sses ssessm ent and/or Disc harge as sessment). sment (PPS a erly ly ( NQ) Ite m Set. This is t he set of i tems act — n OB RA Qu art Quarter ive on a assessm inclu ding S igni ficant C ent ( ction of Prior Qua rterly Assessm ent). This orre item set is used f or a stan dal one Quart erly assessm ent or a Qua rterly as sess ment com ith any type of PPS assessm ent and/or Dischar ge assessm ent . bined w — PPS (NP) Item Set. This is the set of items active on a scheduled PPS assessment (5 - day, 14 -day, 30- day, 60- day, or 90- day). This item set is used for a standalone scheduled PPS assessment or a scheduled PPS assessment combined with a PPS OMRA assessment and/or a Discharge assessment. is is the Th ms active on a ite set of — OMRA - Start of The rapy (NS) I tem Set. stand alone s apy OMRA a ssessm ent. tart of ther OMRA - This is t rapy and Discharge (NSD) Item S et. he set of ite ms Start of The — PPS start of therapy O MRA assessm ent co mbined with a Di scharge ve on a acti ent ( eith er re turn anti ted or not a ntici pated). assessm cipa — OMRA (NO) I tem Se t. This is t he set of ite ms acti ve on a s tandalo ne end of therapy a change of OMRA and MRA assessm ent. The code used is “N O” since this therapy O was t OMRA when the code w as in itia lly a ssigned. he only type of — OMRA - Discharge ( NOD) Ite m Subset. This i s the s et of i tems active on a PPS end sment com of therapy OMRA asses bi ned with a Discharge a ssessm ent ( eith er re turn anti cipa ntici pated). ted or not a stand ND) Item S et. This is t he set of i tems act ive on a — alone OBRA Discharge ( ted or not a ment ( er re turn anti cipa eith ntici pated) to be used w hen a Discharge assess resident is physically discharged from the facility . — Part A PPS Discharge (NPE) Item Set. This is the set of items active on a standalone nursing home Part A PPS Discharge assessment for the purposes of the SNF QRP. It is completed when the resident’ s Medicare Part A stay ends, but the resident remain s in the facility. — Track ing ( NT) Item S et. This is t he set of i tems ac tive on a n Entry Tra cking Record or a Death i n Faci lity T racking Rec ord. 2 s. s) used in the data submission specification (ISC set c odes The codes in paren theses are the item 12 October 2018 Page 2-

36 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual — ion Request (XX) Item S et. This is t he set of i tems act ive on a request to Inactivat te a record SAP syste nationa l M DS QIES A iva m. inact in the Swing Beds • PPS (SP) Item Set. Th is is the — ite ms active on a scheduled PPS as sess ment (5 - set of -day, 30- day, 14 day, or 90- day) or a Sw ing Bed Clini cal Change assess ment. day, 60- This i set is used f or a schedu led PPS assessm ent that is stand alone or in any tem r s wing bed a ents (Swing Bed Clinic al Ch ange combination with othe ssessm ent, OMRA assessm ent, and/or Dischar ge assessm ent). This item set is assessm also used f Bed Clinic al Chan ge assess or a Swing at is s tandalone or in any ment th combination with othe r s wing bed a ssessm ents ( scheduled P PS assessm ent, OMRA assessm ent, and/or Dis sessment). charge as rapy (SS) It em Set. This is the s et of i tems active on a — OMRA – Start of The alone s tart of ther apy OMRA a ssessm ent. stand — rapy and Discharge Ass essment (SSD) Item S et. This is t he OMRA – Start of The set of ms acti ve on a PPS start of therapy O MRA assessm ent co mbined with a ite Discharge a ssessm ent ( eith er re turn anti cipa ted or not a ntici pated). ite — m Set. This is t he s et of OMRA (SO) Ite ms active on a s tandalone e nd of therapy OMRA and change of t herapy O MRA assessm ent. m Set. — OMRA - Discharge As sessment ( SOD) Ite This is t he set of i tems ac tive on a scharge a mbined with a Di er ssment (eith sse PPS end of t herapy O MRA assessm ent co return an anti cipa ted). ticipated or not bed SD) Item S et. This is the set of ite ms acti ve on a s — ne s wing Discharge ( tandalo Dischar ment ( eith er re turn ge assess cipa ted or not a ntici pated). anti — Track ing ( ST) Item S et. This is t he s et of ite ms active on an Entry Trac king Record or a Death lity T racking Rec ord. i n Faci — Inactivat ion (XX) Ite m Set. This is the s et of i tems active on a reque st to ina ctiv ate a record nationa l M DS QIES ASAP syste m. in the Printed lay outs f or the i tem sets are avai lable in Appendix H of this manual. ely de The item set f or a par ticular MDS r ecord is co mplet Type of Provider, termined by the Item A0200 (indicating nursing home or swing bed) , and the reason f ment Ite ms (A0310A, or assess , A0310C, , and A0310H ). I tem set deter mination is co mplicated and A0310B A0310D, A0310F ard MDS so ftware f rom C MS and pri vate vend ors stand uto matical ly make this will a de ter ction 2. 15 of this cha mination. Se anual lookup t ables f or d etermining the pter provides m item set when autom ated so ftwa re is unav aila ble. ond to the O Item Set are t hose values t hat co rresp es BRA -requi red and Medic are- Cod required PPS assessm ents repres ented in I tems A 0310A, A0310B, A0310C , A0310F, and A0310H of eference asses sment types throughout t he rest of t he MDS 3.0. They will be used to r this c hapt er. Leav rge e (LOA ) , which does not requi re co mple tion of ei ther a Discha e of Abs enc ident has a when a res record, occurs t racking : assessm ent or an Entry 13 October 2018 Page 2-

37 CMS’s RAI Version 3. 0 Manual CH 2: Assessments for the RAI • mporary h om e visit of at leas t one night; or Te Therapeu • ght; or tic leave of at l east one ni dm ervat Hospital obs han 24 hours and the hospi tal does not a ion s it the patie nt. • tay less t fer to Chapter 6 a nd the ir Sta te LOA policy f or f urther in formation, if Providers s hould re appli cable. record rs s iate docum entation in the m edical ake appropr regar ding Upon return, hould m provide any changes dent. If th ere are chan ges noted, they s hould be docu mented in the m edical in the resi record. equ ired PPS As sessment s provide inf ormation about t Med icare-R nic al c ondition of he cli bene rec eiving P art A SNF -level ca re in order to be r eimbursed under the S NF PPS f or fici aries Bed provide rs. Medic MDSs can be schedu led or both SNFs and Swing are-required PPS essm ents are coded on the d. These ass ms A03 10B (PPS A ssessm ent) , unschedule MDS 3.0 in Ite (PPS Other Medic are R equired As sess ment – O MRA) , and A0310H (Is this a Part A A0310C : PPS Discharge Assessment?). They include 5- day • day • 14- • 30- day 60- day • • day 90- • SCSA • SCPA Swing Bed Clinic • ange (CCA) al Ch • The rapy (SOT) Other Med icare Requ ired (OMRA) Start of Therapy (EOT) OMRA • End of Both Start a nd End of T herapy O MRA • • Change of T herapy (COT) OMRA • Part A PPS Discharge Assessment Non -Comprehensive MDS assessm ents inc lude a sel ect num ber of ite ms f rom the MDS used to t esident’s s tatus between co mprehensive assess ments and to e nsure m onitor ing of rack the r critical in di cators of the gradual onse t of signi ficant changes i n reside nt st atus. They do not ng. Non- include co the CAA process and care p lanni mpletion of comprehensi ve a ssessm ents rly a include Quarte ction nd Signi ficant Corre to Prior Qu arte rly (SCQA) assess ments. Ob servat Bac k) Peri od is the ti me period over which t he resi den t’s condi tion or ion (L ook side status MDS assess ment. W hen the re aptured by the nt is f irst ad mitted to the nursing is c hom e, the RN ass essm ent coordinat or and t he IDT will set t he AR D. For subse quent ssessm ass or a par ticul ar a tion period f ent f or a par ticu lar resident wi ll be essments, the observa chosen based upon the reg ulat ory requi rements conc erning tim ing and the ARDs of previous assessm ents. Most MDS ite ms the mselves r equ ire an obser vation pe riod, such as 7 or 14 days, . and ends at 11:59 p.m .m vation ., the obser at 12:00 a depending on t he ite m. Since a day begins 14 October 2018 Page 2-

38 CMS’s RAI Version 3. 2: Assessments for the RAI CH 0 Manual pe riod over t his t ime period. W hen co mpleting the MDS, only those occur rences m ust also c ing he lo red. In other words, if it did n ot occur dur riod will be captu the look during t ok back pe ed on the MDS. ba ck period, it is not cod equ ire d Tr acking Rec ord s and As sessm ent s are f ederal ly m andated, and OBRA-R ore, m theref for med f or all r esidents of Medica re and/or Me dic aid cer tif ied nursing ust be per es. These assess al OB on the MDS 3.0 in I tems A0310A ( Feder hom RA Reason ments are coded ent) and A0310F (Entry/ rting). The for Assessm y i nclude: di scharge repo Tracking records • Entry • Death in f acili ty Assessments • Adm ission ( comprehensive) ly • Quarter Annual (c om prehensive ) • om • prehensi ve) SCSA (c • SCPA (c om prehensi ve) • SCQA ipated) • return not an ticip ated or r eturn a ntic Discharge ( Reent ry refers to the situation when all three of the following occurred prior to this entry : the eturned within dent was previo usly in t his facility and was disch arged return an ticipated and r resi r equired to co ity is f acil ity, the mplete 30 da ys of discha rge. Upon the resi den t’s return to t he f acil an Entry t rack I n deter mini ng if the res ident r eturned to the f aci lity w ithin 30 days, the ing record. ity is n discha rom the f acil rge f ot counted in the 30 days. For exa mple, a resi dent who is da y of disc harged r eturn anti cipa ted on Decem ber 1 would ne ed to r eturn to the f aci lity by Dece mber 31 to m day s” req ui rement. eet the “within 30 Res pite refers to sh or t-term, temporary c are pr ovided to a r esident to a llow f amily m embers to giving. take a break the da ily rou tine of care f rom The nursing hom e is required to co mplete an ing record Entry t rack ge assess a nd a n OBRA Dischar ment f or all res pite resi dents. If the res pi te stay is 14 days or longer, the f y m ust have co mpleted an OB RA A dm ission. acilit Required OBRA Assessments for the MDS 2.6 ent is being used f or OBRA require If the assessm RA reason f or asses sment must ments, the OB be coded in Ite ms A03 10A and A0 310F (Disch arge Assessm ent). Me dic are r easons f or er (S assessm bed lat er in th is chapt cri ection 2.9) while the O BRA reasons f or ent are des assessm ent are des cri bed below. ment types The table pr umm ary of t he assess ovides a s and r equire ments f or the OBRA -required hapter. the rem this c ainder of assessm ents, the de tails o f which will be discus sed throughout 15 October 2018 Page 2-

39 required Assessment Summary RAI OBRA- October 201 CMS’s RAI Version 3.0 Manual CAA(s) Assessment MDS Care Plan 14-day 7-day Completion Reference Date Completion Observation Completion Observation Date (Item MDS mission Trans Assessment (ARD) Date Period (Look Date (Item Date (Item Period B2) V0200 8 Back) Consists V0200C2) No Code (A0310A (Item A 2300) No Later B) Z0500 (Look Back) No Later Regulatory Assessment Assessment Later Than Of Ty pe or A0310F) Combination Requirement /Item Set No Later Than Than No Later Than Consists Of Than th A0310A= 01 14th calendar May be h cal CAA(s) endar 14t Admission ARD + 13 ARD + 6 R 483.20 42 CF 14 Care Plan calendar day the of the resident’s Completion Completion (Initial) previous day of (Comprehensive) previous combined day of the resident’s Date + 14 calendar days admission resident’s 42 CFR 483.20 calendar days with an Date + 7 y on admissi (b)(2)(i) (by calendar OBRA (admission date + admission calendar assessment 13 calendar days) (admission date (admissi on da days t the 14th day) days ; e day + 13 calendar + 13 calendar 5- and 14- s) days) day PPS; or Part A PPS Discharge assessment A0310A= 03 ARD + 14 Annual ARD of previous Care Plan May be CAA(s) 42 CFR 483.20 ARD + 14 ARD +13 ARD + 6 OBRA (Comprehensive) combined Completion Completion (b)(2)(iii) previous calendar days previous endar days cal comprehensive (every 12 Date + 7 y with an Date + 14 calendar days calendar days assessment + 366 months) calendar OBRA or calendar days calendar days PPS days assessment AND ARD of previous OBRA Quarterly assessment + 92 calendar days th A0310A= 04 Significant Change 14t 14 calendar day 42 CFR 483.20 Care Plan May be ARD + 6 ARD + 13 14th calendar CAA(s) endar h cal after previous (b)(2)(ii) previous fter day after Completion day a in Status (SCSA) combined Completion calendar days with an det calendar days Date + 14 y determination (within 14 nation ermi Date + 7 (Comprehensive) determination that CH that that significant days) significant change OBRA or signifi cant calendar calendar change in in resident’s days PPS days change in 2 s assessment status occurred resident’s status resident’ : Assessments for the RAI status occurred (determination occurred (det date + 14 ermi nation (determination date + 14 calendar days) date + 14 s) calendar days) cal endar day (continued) Page 2- 16

40 RAI OBRA- required Assessment Summary (con t.) CMS’s RAI Version 3.0 Manual October 201 Care Plan 14-day CAA(s) 7-day Assessment Transmission MDS MDS Completion Completion Completion Reference Date Observation Observation Date (Item Date Assessment Date (Item Period Date (Item (ARD) Period (Look Assessment Code (A0310A V0200C2) No Assessment Regulatory Back) Consists Z0500 B) No Later (Item A (Look Back) 2300) V0200 B2) 8 Combination Later Than or A0310F) Of Than Ty pe Requirement /Item Set No Later Than Than No Later Consists Of No Later Than th A0310A= 05 calendar day Significant 14 ARD + 6 14th calendar ARD + 13 14t h cal endar May be 42 CFR CAA(s) Care Plan Correction to Prior after previous previous day after day a fter Completion Completion combined 483.20(f) determination that Comprehensive determination calendar days calendar days ermi nation det Date + 14 with an (3)(iv) y Date + 7 significant error (SCPA) t significan tha t that signifi cant calendar calendar OBRA or in prior (Comprehensive) error in prior in pri or error days days PPS comprehensive comprehensive ve comprehensi assessment assessment assessment ssm asse ent occurred occurred rred occu (determination (determination ermi (det nation date + 14 date + 14 14 date + calendar days) calendar days) s) endar day cal A0310A= 02 N/A N/A ARD of previous ARD + 6 Quarterly (Non- 42 CFR May be MDS ARD + 13 ARD + 14 483.20(c) Completion Comprehensive) previous OBRA previous calendar days combined calendar days calendar days assessment of any (every 3 with another Date + 14 calendar months) assessment type + 92 dar days calen days A0310A=06 N/A N/A 14th day after Significant 14th day after ARD + 13 ARD + 6 MDS May be 42 CFR determination that Correction to previous determination previous Completion combined 483.20(f) Quarterly Prior significant error calendar days calendar days that significant Date + 14 with an y (3)(v) (SCQA) (Non - in prior quarterly error in prior calendar OBRA or Comprehensive) assessment quarterly days PPS occurred assessment assessment (determination occurred date + 14 (determination calendar days) date + 14 CH calendar days) 2 N/A N/A N/A N/A N/A A0310F= 10 May be Discharge Date Discharge MDS : Assessments for the RAI Assessment + 14 calendar – combined Completion return not days Date + 14 y with an calendar anticipated (Non- OBRA or Comprehensive) days PPS assessment N/A N/A N/A A0310F= 11 N/A N/A Discharge Discharge Date MDS May be – Assessment + 14 calendar Completion combined Page 2- return anticipated days Date + 14 y with an (Non- calendar OBRA or Comprehensive) days PPS assessment 17 (continued)

41 t.) required Assessment Summary (con RAI OBRA- October 201 CMS’s RAI Version 3.0 Manual Assessment Care Plan CAA(s) 14-day 7-day Transmission MDS Completion MDS Completion Completion Observation Observation Reference Date Date Date (Item Assessment Date (Item Date (Item (ARD) Period Period (Look Assessment V0200C2) No Regulatory Back) Consists Code (A0310A Assessment B) Z0500 No Later (Look Back) 2300) B2) (Item A V0200 8 Combination No Later Than Of or A0310F) Later Than Requirement Ty pe /Item Set Than No Later Than No Later Than Consists Of A0310F= 01 N/A N/A N/A Entry Date + 7 Entry tracking Entry Date May not be record calendar + 14 combined days calendar with another days assessment N/A N/A N/A N/A A0310F= 12 N/A Death in facility Discharge May not be Discharge (death) Date + 7 (death) Date tracking record combined with another calendar days +14 assessment calendar days CH 2 : Assessments for the RAI Page 2- 18

42 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH Comprehensive Assessments required co mprehensive asse ssments incl ude the co mpletion of both the MDS and the OB RA- omprehensive as CAA process, as well as care plannin pleted u pon sessm g. C ents are com icant change in a r dent’s status has occu rred or a nif admission, annually, and when a sig esi orre ction to a prior co mprehensi ve as sessm signi ey consist of: ficant c ent is required. Th ission Assessm ent • Adm Annual Assessm • ent Signi Change in Status Assessm ent • ficant Signi ficant Correc tion t o Prior Co mprehensive Assessm ent • thes e assess ment types w ill be discuss ed in deta il in t his se ction. They are not requ ired Each of in swing bed f acil for residents ities. Assessment Management Requirements and Tips for Comprehensive Assessments: look back period, and day 1 f A2300) is the l ast d • the observation/ or The ARD (Item ay of ermine the beg inning of observation/ look back periods. purposes of counting back to det mple, if the ARD is set f or d ay 14 of a residen t’s ad mission, then the beginning of For exa or MDS it the observation period f -day obs ervation pe riod would be day ems requiring a 7 ission (ARD + the obser alend ar day s) , while the beginning of 8 of adm vation 6 previous c period f DS ite ms requiring a 1 4-day observation pe riod would be day 1 of admission or M (ARD + 13 previous calendar days ). ment until ficant Change in Status Assess a Signi mplete • The nursing home m ay not co af ter an OB ission assessm ent has been co mpleted. dm RA A If a resi d • had an OBR A Adm ission assessm ent co mpleted and then goes to the ent l (dis charge ret urn anticipa ted and returns within 30 days) and re turns during an hospita assessment period and most of the assess ment was co alization, mpleted prior to the hospit then the nursing home m ay wish to continue with the origi nal ass essme nt, provi ded the resident does not m iteria for a SCSA. In this c ase, t he ARD r emains the sam e eet the cr and the as ment ent m ust be co mpleted by the completion dates requ ired of the assess sessm e, the type based on the timefram e in which the ass essm ent was st arted. Otherwis om pleted wi ass essment should be rei nit iated with a new ARD and c - ter re thin 14 days af entry from the hospital. The portion of the res t’s asses sm ent that was previo usl y iden completed should be stored on the re siden t’s record with a not ation that the assess ment was rein itiat ed because t he resi dent was hospit alized. ed prior to the co • If a resi dent is disc harg mpletion deadline f sment, completion or th e as ses een co er portions of the R AI th at have b hatev mpleted sment is not required. W of the asses 3 cord, the nursing In closing the re must be mai den t’s m edical rec ord . ntained e resi in th home should note why t he RAI was not co mpleted. 3 The RAI is considered part of the resident’s clinical record and is treated as such by the RAI utilization guidelines, e.g., portions of the RAI that are “started” must be saved. 19 October 2018 Page 2-

43 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI • dent dies p rior to the co mplet ion deadli ne f or the asses sment, c om ple If a resi the tion of ent i ed. W hatever portions of s not requir have been c ompleted m ust assessm the RAI that 4 re ecord t’s m edical r aintained in the . be m siden the record, nursing hom e In closing the AI was not c om pleted. should note why the R If a signi ficant change in • is ide nti fied in the process of c om pleting a ny OB RA status assessm ent except Ad mission and S CSAs, code and com plete the as sessment as a comprehensive SCSA instead. • hom e m ay c om bine a com prehensive assessm ent with a Disc harge The nursing ent. assessm In the pr oc ess of c om pleting any OBRA Comprehensive a ssess ment except an Ad mission • signi SCPA, if tified t hat an unc or rected it is iden ficant e rror oc curred in a previous and a asse ssm ent that has alr eady been subm itted and accep ted into t he MDS syste m, and has mprehensive as not a in a subseque nt co ected sess ment, code a nd co mplete lready been corr the assess ment as a co mprehensive SCPA instead. A corr ection r equest f or t he erro neous assessm ent should also be co mpleted and subm itted. See the sect ion on SCPAs f or and chapt ormation on iled inf or deta er 5 f detai led in formation on com pleting a SCPA, proces ns. ectio sing corr In the pr oc ess of c om pleting any a ssess ment except an Ad mission, if it is iden tified t hat a • revious assessm signi ant ( minor) error occu rred in a p fic ent, cont inue with non- it a correc the asses sment in progress and a lso subm tion completion of re quest f or the erroneous ent as per the ins tructions in Chapter 5. a ssessm • The MDS m ust be t ran smitted (su bm itted and accepted into the MDS da tabase) elec tron icall y no lat er than 14 calen dar days a fter the ca re pl an co mpletion date (V0200C2 + 14 calenda r days). essm ent. The next • The ARD of an assess ment dri ves the due date of the next ass ost re comprehensive assess RD of the m a fter the A cent ithin 366 days ment is due w ment. comprehensive assess May be co mbined with a Medica re-required PPS assessm ent (see Sec tio ns 2.11 and 2.12 • ils) or any Discharge assessment type. for deta RA-required co mprehensive as sessm ents inc lude the f oll owing types, which are num bered OB accor ding to the ir MDS 3.0 assessm ent code (I tem A0310A). 01. ent (A0310A=01) Admission Assessm The A dm ission asse ssment is a co mprehensi ve a ssessm ent f or a new resi dent and, under so me nt t circu ces, a r etur ning reside mstan hat m ust be co mpleted by the end of day 14, counting t he f: date of ad mission to the nursing hom e as day 1 i 4 The RAI is considered part of the resident’s clinical record and is treated as such by the RAI utilization AI that are “started” must be saved. guidelines, e.g., portions of the R 20 October 2018 Page 2-

44 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • siden t’s f irst tim e in this facil ity, OR this is the re not an the resident has been a is f acil ity a nd was disch arged re turn itted to th ticip ated, • dm OR the resident has been a dm itted to th is f acil ity a nd was disch arged re turn a ntic ipated and • etu rn within 30 days of harge. did not r disc ent uirements and Tips for Adm ission Assessm ents: nt Managem Req Assessme Since a day begins at 12:00 a.m. and ends at 1 • ., the actual date of ad mission, 1:59 p.m dless of whether admission occurs at 12:00 am or 11:59 pm, is considered day “1” of regar admission. The ARD (Item A2300) m • no late r than day 14, counting the dat e of adm ission ust be set as day 1. Since a day begins at 1 m. and ends at 11:59 p.m., the ARD must also 2:00 a. his time period. For example, if a resi dent mitted at 8:30 a.m. on Wednesday cover t is ad ed by the end of the day Tuesday (day 14). pleted RAI is requir (day 1), a com Federal st atute and r egula tions requi re th at residents a • sessed promptly upon re as ter than day 14) and the r esu lts are used in planning and providing admission (but no la ate care to at tain or m ainta in the highe st pract icable appropri -be ing. This me ans it is well im es to ass ess a re sident upon the individua l’s admission. T he perative for nursing hom may choose to start and co sse mission com prehensive a IDT ssm ent at any mplete the Ad tim the end of day 14. Nursi ng h om es m ay find early co mpletion of the MDS e prior to te c dividuals with or in articularly f and CAA(s) benef ici al to providing appropria are, p short l engt sessm ent and care plan ning process is o ften acc elerated. hs of stay when the as • T he MDS completion date ( Item Z0500B) must be no lat er than day 14. This date m ay be lier e as the CAA(s) co or the sam ear mpletion date, but not la ter than. than The CAA(s) co mpletion date ( Item V0200B2) must be no l ater than day 14. • • The care pla n co mpletion date ( Item V0200C2) must be no l ater than 7 c alend ar days af ter the C mpletion da te ( Item V0200B2) (CAA(s) completion date + 7 c alendar AA(s) co days). • For a re sident who goes in and out of the f aci lity on a rel ati vely f requent basis and ret urn is expec ted within t he next 30 days, the resident m ay be discharged with return cipat anti ed. eturns This st atus r equires an Entry t rack ing record each time the reside nt r each time to the f Dis charge as sessm ent n OBRA the re sident is disch arged. ity and a acil The nursing hom e m ay c ombine the Ad mission a ssessm ent with a Dischar ge assessm ent • able. when applic Annual Assessment (A0310A=03) 02. The Annual assess s a co mprehensive as sessm ent f or a resident th at m ust be co mpleted on ment i an annual ba sis ( at l east every 366 days) unle ss a SCSA or a SCPA has been co mpleted since the most recent co mprehensive assess ment was co mpleted. Its completion dat es (MDS/CAA(s)/ca re mpletion plan) depend on the most re cent comprehensive and past assess ments’ ARDs and co dates. 21 October 2018 Page 2-

45 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH Assessme Req uirements and Tips for Annual As sessm ents: nt Managem ent The ARD (Item A2300) m within 366 d ays a fter the ARD of the previous • ust be set om ve a ssessm ent (ARD of previous comprehensive as sess ment + 366 RA c OB prehensi ys) AND within 92 days since the ARD of the previous OBRA Quarterly or calend ar da ficant Correc terly asse ssm ent (A RD of previous OB RA Quarte rly Signi tion to Prior Quar dar days). assessm ent + 92 calen The MDS completion date ( Item er than 14 days af ter the A RD • Z0500B) must be no lat calend ar da ys). This da te m ay be ear lier (ARD + 14 he sam e as the CAA(s) than or t completion date, but not lat er than. The CAA(s) co Item V0200B2) must be no l ater than 14 da ys a fter t he • mpletion date ( e, ARD is date may be the sam e as the MDS co mpletion dat dar days). Th ARD ( + 14 calen lier than. but not ear The care pla n co mpletion date ( Item V0200C2) must be no l • than 7 c alend ar days ater af ter the C mpletion da te ( Item V0200B2) (CAA(s) completion date + 7 c alendar AA(s) co days). Significant Change In Status Assessment (SCSA) (A0310A=04) 03. s a co mprehensive as sessm The SCSA i or a reside nt th at m ust be co mpleted when the IDT ent f the sig er major ines for eith guidel has det ermined that a r esident m eets ant change nific can be per me af ter the co mpletion of an A dmission ed at any ti improvement or decline. It form mpletion dates ( MDS/CAA(s)/care plan) depend on the dat e that the I DT’s ass essment, and its co ade that the resi dent h ad a signifi ermination was m det cant change. A ant change” is a major dec line or i mprovem “signific tatus that: t’s s ent in a residen 1. Will not norm ve it self wit hout int ervention by staff or by i mplementing ally resol terventions, the decline is not considered “s in cli nical related ease- standard dis elf- lim g”; itin 2. Im pacts more than one a rea of siden the re alth status; and t’s he 3. Requires in terdis ciplinar y review and/or revision of the care plan. fle cts an actual signif ffers from a significant error because i A significant change di t re icant change in the resident’s health status and NOT rec t co ding of the M DS. in cor equ ferral for a Preadmission Scr eening and Resident A significant change may r ire re (PASRR) evaluation if a mental il lness, inte Review al d isabili ty ( ID ), or related llectu esent or is condition is pr to be pr esent. suspected Asse ssme nt Managem ent Req Significant Change in S tatus uirements and Tips for Assessments: er the resident m eets the SCSA When a res ident’s status changes and it is n ot clear wheth • guidelines, the nursing home may take up to 14 days to de term ine whet her the cr iteria are met. 22 October 2018 Page 2-

46 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • DT has det ermined that a resident m eets t he sig ni ficant change guide lines, the After the I um ent the i al i den tification of a s igni ficant c hange in t he nursing hom e should doc niti . the clinical record resident’s s tatus in SA is appropri • hen: A SC ate w There is a deter mination that a signi ficant change (either i mpr ove ment or decli ne) in a — rom er bas c ondition f eline h as oc curred as indi cated by com parison of resident’s his/h nt ’s curre tatus to the m ost re cent com prehensive assessm ent and any ide the res nt s ly a ssess ments; a nd subsequent Quarter eturn The resi t’s condi tion is not ex pect ed to r den to bas eline within two weeks. — For a re sident who goes in and out of — aci lity on a rel ati vely f requent basis and the f reen e xpected w ithin the next 30 days, the r eside nt m ay be disch arged with try is an ticipated. This requ ires an Entry t racking r eco rd each t ime the res ide nt return s tatus ment each t he f ity a nd a n OBRA Dischar ge assess ns to tim e the resi dent i s retur acil arge d. However, if the IDT det ermines that t he resi dent would bene fit f rom a disch ficant Change in Status Asse ng period, t nterveni Signi he staf f m ust ssment during the i is only a dent h as had an OBRA complete a SCSA. This llowed when the resi issi on assessm ent co mpleted and subm itted prior to di scharge ret urn an ticip ated Adm resident r when the OBRA A (and dm issi on assess ment is eturns within 30 days) or nt r ith the discharge r combined w cipated a ssessm ent (and reside eturn eturns a nti within 30 da ys). ent. ission assessm rior to an OBRA Adm pleted p • A SC SA m ay not be com • SA is required to be per formed when a ter mina lly i ll resident enr olls in a hospi ce A SC (Medica -licensed h ospice provider) or changes hospice program re-certified or State and re mains a r esident at t he nursing hom e. The ARD m providers thin 14 days ust be wi from fecti ve date of the hospice elec tion (w the ef he sam e or lat er than the hich can be t date of the h ospice e lection sta tement, but not e arlier than). A SCSA m ust be per formed regar assessm ent was recently conducted on the re side nt. This is to whether an dless of ensure a co ordin ated pl an of care between the hospice and nursing hom e is in place. A Medicare -certif ied h ospice m ust conduct an a ssess ment at the i nit iation of its ser vices. e to ev This iate t ime f or t he nursing hom is an appropr aluate the MDS i nformation to mine if deter rent condi it r eflects t he cur tion of the res ide nt, since the n ursing ho me remains responsible f or p ary c are and s ervi ces to as sist the resi dent i n roviding necess oce his/h hest pr acticable well achieving t whatev er stage of the d isease pr er hig ss -be ing a the r eside nt is ex per iencing. • If a resi dent is ad mitted on the hospi ce benef it (i .e. the r esid ent is co ming into the f aci lity having a lready ele or elects hospice on or prior to the ARD of the cted hospice), the f acil Admission assessment, uld co mplete the Ad mission assessm ent, checking ity sho the Hospice Care i tem, O0100K. C om pl eting an A dm ission assessm ent f ollowed by a SCSA is not required. Where hospice election occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice election so that only the Admission assessment is required. In such situations, an SCSA is not required. • ces and SA is required to be per formed when a resi dent is rece iving hospice s ervi A SC n as revoki ng of ARD e). The hospice car then de cides to discontin ue those s ervices (know 23 October 2018 Page 2-

47 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH must be within 14 days from one of the following: 1) t he effecti ve date of the hospice ich can be t he sam er than the date of the h ospice e lection election revocation (wh e or lat ment, but not earl than ); 2) t he expir ation date of the ce rti fication of tate revocation s ier he date of the physic ian’s or m edical direc tor’s order st ating the ter minal illness; or 3) t rm s no longer te resident i inally ill. If a resident is admitted on the hospice benefit but decides to discontinue it prior to the • ARD of the Admission assessment, the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by a SCSA is not required. Where hospice revocation occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice revocation so that only the Admission assessment is required. In such situations, an SCSA is not required. The ARD must be les s than or equal to 14 days after the IDT’s determination that the • criteria for a SCSA are met (determination date + 14 calendar days). • The MDS completion date ( Item Z0500B) must be no lat er than 14 days from the A RD calend ar da (ARD + 14 ater than 14 days a fter the deter minat ion that the ys) and no l criteria f SCSA were met. This date m ay be ear lier than or the sam e as the CAA(s) or a er than. completion date, but not lat When a SC SA is co mpleted, the nur sing h ome mu st re view all trig gered care ar • eas ’s pre vious s tatus. If the CAA process indic ates no change in a compared to the resident rea, then the p rior documentation for the pa rticul care a ay be car ried ar care area m forward, and the nursing home should specif he sup porting documentation can y where t ted in edical record. be loca the m The CAA(s) co • Item V0200B2) must be no l ater than 14 da ys a fter t he mpletion date ( eter r the d r than t he ARD ( ARD + 14 calen dar days) and no late mination that 14 days afte criteria f or a met. This date m ay be the same as the MDS co mpletion date, SCSA were DS c pletion. lier than M but not ear om T • than 7 c n co Item V0200C2) must be no l ater he care pla alend ar days mpletion date ( AA(s) co mpletion da te ( Item V0200B2) (CAA(s) completion date + 7 c alendar af ter the C days). ines Deter mi ning a S ign ificant Ch ange in a R esiden t’ s S tatus: Guidel for this is not Note: st an exhaustive li inal d ecision The f ding what constitutes a signi ficant change in s tatus must be based upon regar the judgment of the IDT. MDS asses sm ents are not req uired for minor or t em porary var iations in resident s tatus - in these cases, t he r esiden t’s co ndition is ex pected to return to base line within 2 weeks. Ho wever, s f must note thes e tran sient changes in the resi den t’s status in the resident’s taf rven and implem ary as record ment, car e planning, and cli nic al inte ent necess tions, even sess though an M DS assessm ent is n ot r equired. Som e Gui delin es to Assist in Decidin g If a Change Is Significant or Not: • A condition is def ined as “sel f-limiting” when the condition will nor mally resolve itself without furt ical ntervention or by s taf f implementing s tandar d diseas e-rel ated c lin her i the co olved ndition has not res within 2 weeks, staff should begin a inte rven tions. If 24 October 2018 Page 2-

48 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH SCSA. This ay vary depending on cli nical judg ment and resident n eeds. For tim eframe m l oss f exam the flu would not nor mally meet the or a re ple, a 5% weight sident with SA. In gener e f ght loss m ay be an expect ed outcom or a SC or a requi rements f al, a 5% wei lu who exper d nausea and diarr hea f or a week. In this s itu ation, th the f resident wi ience onitor the reside nt’s s tatus and a ttem pt various int sta tions to re ctif y t he ff should m erven If the res come dehy drated and st arted to reg ain immediate weight loss. ident did not be the sy d not be re s subsided, a com prehensive a ssessment woul fter quired. weight a mptom ore areas of ate if there are e ither two or m SA is appropri decline or t wo or more • A SC i mprove ment. In this e xampl e, a res ident with a 5% w areas of loss in 30 days would eight not gene re a S CSA unless a second a rea of decline acco mpanies it. Note th at rally requi ssumes that the car a lready been m odi fied to acti vely t reat the weig ht loss this a e plan has with the or , “potenti em o continuing al f or weight loss.” This as opposed t iginal probl um ation should be doc den t’s cli nical record along w ith the plan fo r situ ented in the resi m onitoring and, if the p roblem persi sts or worse subsequent m ay be ns, a SCSA warran ted. esident would ff m ay st ill d ecide that the r , sta bene fit f rom a • If there is only one change remember that each SCSA. It is important to sident’s s ituat ion is unique and the IDT re must sion as to wheth er or not the r make the deci nt will bene fit f rom a SCSA. eside ord, f edical rec t’s m den he resi Nursing hom es m ust docum ent a rat ionale, in t or completing a SCSA that does not m eet the cr mpletion. iteria f or co stent pa A SC iate if ere i s a consi SA is also appropr ttern of c hanges, with eith er two or • th decline or t wo or more areas of i mprove ment. This m ay include two more areas of decli thin a pa main ( e.g., two ar eas of ADL rticular do ne or i mprove ment). changes wi A SC ate i n situ SA would not be a ppropri • ations where the r esident has s tabi lized but is utur expected arged in the i mmedia te f be disch e. The nursi ng h om e has engaged in to dischar ge p lanning with the re side nt and f amily, and a co mprehensive re assessm ent is not necess ary to f acil itate d ischarge pla nning. • Decline in t wo or more of the f ollo wing: Residen sion- — making ability has changed; t’s deci ly r — a resi dent m ood item not previous Presence of eported by t he resi dent or sta ff © ), e.g., incr ease in the num ber and/or an i 9 he sy ncreas mptom f requency ( PHQ- e in t of areas where behavior al sy mptom s are coded as being pre sent and/ or the f requency of a s ymptom increas es f or ite ms in Section E ( Behavior ); — Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; al f unctioning area (at least 1) where a resi dent is — Any decline in an ADL physic new a ssista nce, To tal depende nce, or Act ivity did not oc cur ly coded as Extensive sin ce last assessm ent and does not reflect normal fluctuations in that individual’s functioning; — Residen t’s i ncontine nce patt ern cha nges or th ere was placem ent of an in dwelling cath eter; 30 days or 10% change (5% change in — Emergence of unplanned weight los s problem ); in 180 days 25 October 2018 Page 2-

49 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH — ergence of a new pressure u lcer at Stage 2 or higher, a new unstageable pressure Em ulcer/injury, a new deep tissue injury or worsening in pr essure ulcer status; egins to use a res traint of any type when it was not used bef ore; and/or Resident b — — Emergence of a condition/disease in which a resident is judged to be unstable. • Improvement in two or more of the following: Any improvem ent in an ADL physical functioning area (at least 1) where a resi dent — is as In mited assis tance since las t as sessm ent newly coded dependent, Supervision, or Li and does not reflect normal fluctuations in that individual’s functioning; oral sy the num ber of areas where Behavi — mptoms are coded as being Decrease in and /or the f present ency of a sy mptom decreases; requ — Residen t’s deci sion making improves; Residen patt ern improves. — t’s incontinence les (SC amp SA): Ex Mr. T no longer responds to verbal requests to alter his screaming behavior. It now occurs 1. daily and has neither lessened on its own nor responded to treatment. He is also starting to resist his daily care, pushing staff away from him as they attempt to assist with his ADLs. This is a significant change, and a SCSA is required, since there has been deterioration in the behavioral symptoms to the point where it is occurring daily and new approaches are needed to alter the behavior. Mr. T’s behavioral symptoms could have many causes, and a SCSA will provide an opportunity for staff to consider illness, medication reactions, environmental stress, and other possible sources of Mr. T’s disruptive behavior. 2. Mrs. T req uired m inim al assi stance with ADLs. She f ractu red her hip and upon return to the stan facil ten siv e assi uires ex ce with a ll ADLs. Rehab has sta rted and staff is hopeful ity req el of function in 4- or lev urn to her pri she wi ll ret 6 weeks. 3. e for 5 weeks following an 8- week acute hospital iza tion. Mrs. G has been in the nursing hom dm On a ery f rail, had troubl e thi nking, was c onfused, and had m any ission she was v behavior al com plica tions. The cours e of treat ment led to st eady i mprovement and she is now stab ting inappropri ate behaviors. T he resi dent, her le. She is no longer confused or exhibi family, and staff agree t hat she has m ade r emarkable progre ss. A SCSA is req uired at this tim e. The resident is not the person s he was at admission - her in itia l pro ble ms have resolved dis and she will be remaining in the f acility. A SCSA will p erm it the inter cipli nary team to review h care for the future . n a new course of er needs and pla Guidel i nes for When a Change in Resid ent Status Is N ot Signific ant: this is not Note: st an exhaustive li • Discret e and eas ily rev ersible caus e(s) documented in the res ident’s record and for which the IDT can init iate co rre ctive action (e.g., an anti cipated side e ffect of intr oducing a ive dose level. psychoactive m edicati on while att em pting to es tab lish a c lin ical ly e ffect quire a SCSA) Tapering and monitoring of dosage would not re . 26 October 2018 Page 2-

50 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: which the erm acute i lln ess, such as a m ild f ever secondary to a cold f rom Short-t IDT • the r esident to f ully r ecover. expects Well -es tab lished, predict able cy clic al patt erns of clinical sig ns and symptom s associ ated • usly diagnose with previo ssive sy mptom s in a resi dent previo usly d conditions (e.g., depre ith bip ld not prec ipitate a Signi ficant Change Assessm ent). diagnosed w olar disease wou Instan ces in • sident continues to m ake steady progress unde r the curr ent which the re course of ca re. Reassessment is required only when the con dition has s tabil ized. • Instan ces in which the re sident has s tabi lized but is expe cted to be dischar ged in the imm ediate future. The lity h as engaged in di scharge pla nning with the resi dent and faci ily, and a co ge eass essm ent is not neces sary to f acil itate dischar fam mprehensive r planning. inal Guidel Deter mi ning the Ne ed for a SCSA for Residents with Term ines for Conditi ons: Note: this is not an exhaustive li st The key in deter mining if a SC SA is requir ed for individuals with a terminal condi tion is whether or not the change in condition is an e rt of the d ise ase cour se and is xpected, well-defined pa consequentl ressed as p art of the overa ll p lan of car e for the individua l. y being add is not If a ter minal ly i ll resident exper ience s a new ons et of sym ptom s or a co ndition that • SCSA, a S or a A CS part of the e xpected co urse of det eri ora tion and t he cr iteria are m et f assessm ent i ired. s requ • If dent ele cts the M edica re Ho spice pro gr am , it is important th at the a resi two separate ent (nu rsing hom e and hospice program sta ities nate thei r respo nsibilit ies and ff) coordi develop a ca re plan re fle cting the i nterven tions required by both ent iti es. The nursing home and hospice plans ective of the c urrent st atus of the resi dent. ould be refl of care sh Ex amp les (SC SA): 1. Mr. M has been in t his nursing hom e for two and one- half years. He has been a favor ite of sta other re sidents, and his daughter has bee n an act ive volunteer on the unit. M r. M is ff and now in the end stage of his cours e of chronic dementia, diagnosed as probable Alzhei mer’s. He experiences r ecur rent pneumonias and swallowing di fficulties, his prognosis is g uarded, bers ar and fam ily mem re of e fully awa his st atus. He is on a speci al dem entia u nit, st aff has detai led p re protocols f or all s uch end stage r esi dents, and ther e has been a ctive all iative ca are p rred, s taff has involvement of his daughter in the c lanning process. As changes have occu n a ti mely, appropri ate m anner. In this case, Mr. M’s c responded i of a high quali ty, and are is as his physic al s tate h as decli ned, there is no ne ed for sta ff to co mplete a new MDS assessm ent for this bed fast, highly dependent term inal resid ent. able pro 2. the n ursing hom e with ide ntifi Mrs. K came into blems and has s tead ily r esponded to tre atment. Her condi tion has i mproved over time and has rece ntly h it a p lateau. She w ill be er care. The course of dischar within 5 day s. The in itial RAI helped to set goals and star t h ged care provided to Mrs. K was modif ied as neces sary to ensure continued improvem ent. The the causes of ent need the resident’s condition. An assessm rsed IDT’s tr eatment response reve 27 October 2018 Page 2-

51 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH not be completed acil ities have 14 days to in view of the i mminent discharge. Remember, f ident’s condition has s complete an assess Mrs. K is tabil ment once the res ized, and if ment is not r ired. If the r esiden t’s di scharge within this period, a new assess equ dischar ged essment is r equired by the end of the all plans chan ge, or if she is not dischar ged, an ass otted 14-day period. Mrs. P, too, has responded to care. Unlike Mrs. K, however, s he continues to i mprove. Her 3. ate has n ot b een speci dischar She is benef iting f rom her c are and f ull r est ora tion of ge d fied. ili ties atment is focused appropriately, her functional ab s eems possible. In this case, tre ation, and ther by ade, staff is on top of the situ e is nothing to be gained progress is being m wever, if her condition wa requiring a SCSA at this tim bil ize and her di scharge e. Ho s to sta r. was not imminent, a SCSA would be in orde ines for Deter mi ning When A Sig nific Guidel ld R esult in Referral for a ant Change Shou Prea iss ion Screeni ng and Resident Revie w (PAS RR) Level II Ev aluati on: dm If a SCSA occurs f individual known or suspected to ha ve a m ental illness, or an • ili ty ( “m ental retardation” in the regu latio n), or re lated condition (as llectual disab inte ral to the Sta te M ental He alth or Intellectual defined by 42 CFR 483.102), a refer authori or a ID /DDA) f Disability/Developmental Disabilities Administration ty (SMH/ ation ly occur as requi red by Section must prompt possible Level II PASRR evalu 5 cial Securi . )( iii) of the So 1919(e)(7)(B ty Act PAS RR is not a req uir • sessment process, but i s an OB RA ement of the resident as provision that is requ ired to be coordinated wi th the resident assessment process. Thi s te PAS guidel line — the guide RR with the SCSA ine is intended to help f aci lities coordina does not require any ac the SCSA itself. tions to be taken in co mpleting require Faci hould look to the ir st am liti es s ments for specif ic proced ures. • ate PASRR progr RR contact in formation for the S MH/ ID /DD A authorit ies and the Sta te Me dicaid PAS . ble a Agency is availa p://www.c ms.gov/ t htt • The nursing f acil ity must provide the SMH/ ID /DDA authorit y with re fe rrals as descri bed below, independent of the findings of the SCSA. P Level II is to function as an ASRR independent assessm ent process for this population wit h speci al n eeds, in paral lel with the f aci lity’s as sessment process. Nursing f aci lit ies sh ould have a low threshold f or ent referr al to the SMH/ ID /DDA, so that thes e auth ori ties m ay exerci se th eir expert judgm about when a Level I luation is needed. I eva acility • Re ferral sh ould be m ade as soon as t he cr iteria i ndicat ing su ch are evident — the f should not wait un til the SCSA is c om plete. 5 efer Th e s tatute ma y a lso be r e the statut en ced as 4 2 U.S .C. 1 396r (e)( 7)(B)(iii ). Not e th at as of this revis ion dat e wh sup ed es Federal r egula tion s at 42 CFR 483.1 14(c), ers ich s till rea ds as requir ing annu al res iden t review. Th e nge i n cant cha regula tio n has not yet b een updat ed t o ref lect th e s tatuto ry chang e to res iden t revi ew upon s ignifi ition. cond 28 October 2018 Page 2-

52 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH Referral for Level II iew Eval uations Is Required for I ndiv iduals Previously Resident Rev Intellectual Disab /Developmental Identified by PAS RR to Have Mental Illness, ility in the Foll ndition Circ umstances: , or a Related Co Disability owing Note: this is not an exhaustive list A resident who dem onstrates incr eased behavioral, ps ychi atric, or mood- related • s. symptom A resident with behavio ral, psychia tric, or mood rela ted sy mptoms that have not • ment. eat responded to ongoing tr A resident who experien ces an i • edical condi tion—such tha t the resident’s plan mproved m lacem ent re comm endations m ay req of care or p ications. uire modif • A resident whose signi fic ant change i s physic al, but with behavioral, psyc hia tric, or fluence adj rel itive abi liti es, t hat m ay in s, or cogn ustment to an mood- ated symptom attern of daily li ving. alt ered p A resident who indica tes a pref eren ce (m ay be co mmunicated verbal ly or through othe • r forms of communicati ) to leave the fac ili ty. on, including behavior cantly di atment is or wi ll be signifi • fferent than A resident whose condition or tre bed in descri s m ost recent PASRR L evel II eval uation and deter mination. the resident’ is req uation ASRR eval possible ne (Note th at a re ferr al f or a uired whenever w Level II P such a dispa rity ated wi th a SCSA.) is discovered, whether or not as soci le (PA SC SA): amp Ex SRR & M 1. rim r. L llne ss, bu t his p ental i ary reason f or adm ission was has a diagnosis of serious m ract ract ure. Once the hip f rehab ure resolv es and he beco mes ili tation following a hip f ambulatory, even if other conditions e h Mr. L re ceives m edical care, he sh ould xist for whic mine whether a change in h erred f evalu ation t o deter be ref is placement or or a PASRR servi ces is needed. Referral for Level II Resident Rev iew Eval uations Is Also Required for Indivi duals Who May Not Have Previ ously Been Identified by PASR R to Have Mental Illness, Intellectua l Disa bil ity /Developmental Disability on in the Foll owing , or a Related Conditi Circ umstances: Note: an exhaustive list this is not A resident w ho exhibi • al, psychia tric, or mood related symptom s suggesting ts behavior the pres ence of a diagnosis of m ental illness as def ined under 42 CFR 483.100 (where dem entia is not the pri mary diagnosi s). • A resident whose int ellec tual disab il ity as de fined under 42 CFR 483.100, or rel ated condition as defined under 42 CFR 435.1010 was not previo usly ide ntified and evalua ted through PASRR. tric A resident tr ans ferred, admitted, or r • mitted to a NF f ollo wing an inpatient psychia ead tensive tre ent. atm stay or eq ual ly in 29 October 2018 Page 2-

53 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 04. Significant Correction to Prior Comprehensive Assessment (SCPA) (A0310A=05) sessm ent f or an exis mprehensive as esident tha t must be co mpleted when The SCPA i s a co ting r ines that a resi den t’s prior co mprehensive as sess ment contains a sig nif the IDT det err or. erm icant ed at any ti ter the co mplet ion of an A dm ission assessment, and its ARD It can be perform me af s (MDS/CAA(s)/care plan) depend on the date t he det ermination was m ade and co mpletion date the sig nif icant e that in a comprehensi ve assess ment. rror exists “signific ant error” is an err or in a n assess ment where: A presented (i.e., miscoded) on The resi den t’s overa ll cl inical st atus i s not accura tely re 1. roneous assessment and/or results in an inappropriate plan of care; and the er cted v or h as not been c orre The err ia submission of a m ore recent as sessm ent. 2. t co A significant er ror dif fer s from a signif icant ch ange because it ref lect s incor rec ding of lth res an actual significant change in the the MDS and NOT s hea ident’ status. Significant nt Managem Prior Correction to Assessme Req uirements and Tips for ent Assessments: Comprehensive • error in an ant fic fication of a signi nti itia l ide ment the in Nursing homes should docu . ent in the clinical record assessm te when: • PA is appropria A SC een co mpleted and ment has b sess mprehensive as the erroneous co — trans d/subm itted into the MDS syste mitte m; and udes a ssment in prog — ore curr ress or co there is not a m mpleted that incl ent asse n error. tem(s) i the i to ection corr The ARD or in • the icant err nif t a sig the determination tha ter must be within 14 days af mination dat e + 14 calendar days). prior co mprehensive as sessm ent occurred ( deter • Item Z0500B) must be no lat er than 14 days af ter the A RD The MDS completion date ( calend the deter ys) and no l ater than 14 days a fter (ARD + 14 minat ion was m ade ar da that a signi ficant e rror occurred. This date m ay be ear lier than or the sam e as the CAA(s) e. completion date, but not lat er than the CAA(s) co mpletion dat T • he CAA(s) co V0200B2) must be no l mpletion date ( fter t he ys a ater than 14 da Item dar days) and no m ARD ( ore th an 14 days a ARD the determination was + 14 calen fter e as the MDS completion ficant e rror o ccur red. This date m ay be the sam made that a signi mpletion date. the MDS co than lier date, but not ear mpletion date ( n co The care pla • ar days alend than 7 c ater V0200C2) must be no l Item alendar A(s) co mpletion da te ( Item V0200B2) (CAA(s) completion date + 7 c af ter the CA days). 30 Page 2- October 2018

54 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Non-Comprehensive Assessments and Entry and Discharge Reporting om ents include a sel ect number of MDS ite ms, OB prehensive MDS assessm RA-required non-c co mpletion of the CAA process and ca re planning. The OBRA n but comprehensive not on- assessments include: • Quarter ly Assessm ent Signi ficant Correction to Prior Quar terly Asses • ent sm • Discharge Assessm ent – Return not Anticip ated ed Assessm ent – Return Anti cipat • Discharge assessm icant Corr The Quarterly and Signif or Quart erly ection ents are not req uir ed for to Pri Swing Bed residents. However, Swing Bed provi ders ar e required to co mplete the OBRA Discharge assess ments. ed for cords in ect n umber of MD Tracking ms and are requir clude a sel all re sidents in the re S ite e and swing bed f acil ity. They include: nursing hom Entry Trac king Record • • ili ty Trac king Record Death in Fac Assessme ent Req uirements and Tips for Non-Comp rehensive Assessments: nt Managem • The ARD is consider ed t he las t day of the observatio n/look back period, t heref ore i t is day 1 for purposes of counting back to determine the beginning of observation/look back periods. For example, if the ARD is set f or Ma rch 14, then the beginning of the observation period f or M DS ite ms requiring a 7 -day observat ion period would be previous calendar days rch 8 (ARD + 6 Ma ), while the beginning of the observation period f or MDS ite ing a 14-day observation pe riod would be March 1 (A RD + ms requir r da 13 previous calenda ys). • If a r esi dent goes l (dis charge r eturn anti cipat ed and returns within 30 day s) to the hospita and ret urns during the a ssessment period and most of the as sessm ent was co mpleted prior to the hospit ome may wish to continue with the orig inal sing h ali zation, then the nur assessment, provided the resident does not m eet the cr iteria f or a SCSA. mple: For exa th . The f aci lity s taff sess ment with an A RD of March 20 — Resident A has a Quar terly as ment. The resi finished most of the as sess return dent is dischar ged ( an ticipated) to the rd th hospital on March 23 . Review of the in formation f rom and returns on March 25 ot a char al revea ls th at t here is n the dis ny signi ficant change in status f or ging hospit the resident. Therefore, t he f acil ity s taff continues with the ass ess ment that was not rd fully ischarge and may complete the assess ment by April 3 ore d completed bef ter the ARD). (which is day 14 af th Resident B a lso has a Q uart erly a sse ssm ent with an ARD of M arch 20 — . S he goes to th th icant hile the . W nif re is no sig and returns March 30 tal on March 20 the hospi 31 October 2018 Page 2-

55 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI nd ecides to s tart a new asses sment and sets the ARD for April 2 change the faci lity d ses mpletes the as sment. and co If a resi dent is disc harg • his assessm ent process, th en whatever portions of t he ed during t 6 mpleted m aintained in the re siden t’s di scharge r ave been co . ecord RAI that h ust be m In AI was not c he nursing hom e should note why the R ecord, t om pleted. closing the r If a resi dent dies dur ing t his asse ssm • ss, c om pletion of the asses sment is not ent proce requi hatev er por tions of the RAI that ha red. W mpleted m ust be maintained in ve been co 6 ide nt ’s m ecord. the res edical r osing the rec sing h om e should ord, the nur When cl mpleted. w hy the RAI was not co document If a signi ficant change in status is • fied in the process of c om pleting a ny assess ment ide nti except Ad mission and S CSAs, code and com plete the as sessment as a co mprehensive SCSA instead. • In the pr oc ess of c om pleting any a ssess ment except an Ad mission and a SCPA, if it is evious com iden igni ficant err or occurred in a pr hat a s prehensive as sess ment that tified t has al ready been subm itted and a ccepted i nto the MDS syst em and has not a lready been ment corr in a subseque nt co mprehensive as sess ment, code a nd co mplete the assess ected as a co mprehensive SCPA instead. A corr ection r equest f or t he erro neous comprehensive CPAs f ection on S itted. See the s mpleted and subm or assessm ent should also be co detai led in om pleting a SCPA, and Chapter 5 f or det ailed in formation on formation on c sing c ctions. proces orre In the pr oc ess of c om pleting any a ssess ment except an Ad mission, if it is iden • hat a tified t non- fic ant ( minor) error occu signi revious assessm ent, cont inue with rred in a p completion of the asses sment in progress and a lso subm it a correc tion re quest f or the erroneous a ssessm tructions in Chapter 5. ent as per the ins • ment dri ves the due date of the next ass essm ent. The next non- The ARD of an assess comprehensive assess ment is due w ithin 92 days a fter the A RD of the m ost re cent OBRA assessm ent ( ARD of previous OB RA assess ment - Ad mission, Annual, Quarterly, sessment - Signi ficant Change in Status, or Si gnificant Co rrect ion as + 92 calend ar d ays). • AA process is not r equ ired with a n on -comprehensive as sessment (Quarterly, While the C om till requ ired t o review t he in formation f rom these SCQA), nursing h es are s ents, and review and revise the resident’s care plan. assessm bm • m ust be t ran smitted (su The MDS itted and accepted into the MDS da tabase) elec tron icall y no lat er than 14 calen dar days a fter the MDS co mpletion dat e (Z0500B + 14 calend ar days). m -comprehensi ve as sessm • Non ay be co mbined with a M edica re-req uired PPS ents assessm ent ( see Sect ions 2.11 and 2.12 f or deta ils). 6 The RAI is c onsidered part of the res n ical reco rd and is treat ed as such by the RAI utilizatio ident’s clin aved. hat are “started” must be s s of the RAI t es, e.g., portion guidelin 32 October 2018 Page 2-

56 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 05. Quarterly Assessment (A0310A=02) ssment is an OBRA non- ent f or a resi dent th at must be ly asse comprehensive assessm The Quarter ery 92 days following the pr evious OBRA assessme nt of any type. It is used completed at le ast ev ments to ensure siden tat us between co mprehensive assess t’s s cr itical in dicators of ack a re to tr ch ange in a r esident’s status are monitored. As such, not al l MDS ite ms appear on the gradual ly a Quarter ent. The ARD (A 2300) must be not more than 92 days af ter the A RD of the ssessm RA assess y type. most recent OB ment of an nt Managem ent Req uirements and Tips: Assessme at a minimum • uire ments dic tate that, Federal , three Quar terly asse ssments be req completed in each 12-month period. Ass uming the resident d oes not have a SCSA or -month e, a typical 12 ged from the nursing hom and was not dischar SCPA c ompleted OB RA schedule would look like this: OB RA assessm ents • ay be schedu led early if a nursing hom e wants to s tagger due dates m for assessm ents. As a result, m ore th an three OBRA Quarterly assess ments m ay be completed on a part icu lar re sident in a given year , or the Annual ass essm ent m ay be gula completed early to ensur e that the re tory ti me f rames are met. However, Sta tes m ay have m ore stringe str ictions. nt re of must be within 92 days af • the ARD The ARD the prev ious OBRA assessm ent ter (Quart erly, Admission, SCSA, SCPA, or Annual assessm ent + 92 calen dar days). he MDS completion date ( Item Z0500B) must be no lat er than 14 days af ter the A RD • T ys). ar da calend (ARD + 14 33 October 2018 Page 2-

57 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 06. Significant Correction to Prior Quarterly Assessment (SCQA) (A0310A=06) non- The SCQA i m ust be co mpleted when the IDT comprehensive asse s an OBRA ssment that ant er esident’s p arte rly as sessment contains a signi fic hat a r ror. It can be mines t deter rior Qu per at any tim e after the co mple tion of a Quart erly a sse ssment, and the ARD (It em form ed pletion dates (It em Z0500B) depend on the date t he det erm ination was m ade A2300) and com there is a signi fic that error in a previous Quar terly asse ssm ent. ant “signific ant error” is an err or in a n assess ment where: A presented (i.e., miscoded) on The resi den t’s overa ll cl inical st atus i s not accura tely re 1. ent; and roneous assessm the er cted v ent. or h as not been c orre The err ia submission of a m ore recent as sessm 2. t co A significant er ror differ s from a signifi cant ch ange because it ref lec ts incorrec ding of s hea ident’ an actual significant change in the res the MDS and NOT atus. lth st uirements and Tips: Req Assessme nt Managem ent Nursing homes should docu • nti error in an ant fic fication of a signi itia l ide ment the in ent in the clinical record assessm . ate when: QA is appropri • A SC — MDS c plet ion date, Ite om ent has been com m rly assessm the erroneous Quarte pleted ( m; and he MDS syste into t itted itted/subm Z0500B) and transm ress or co mpleted that incl udes a — there is not a m ssment in prog ent asse ore curr n error. corr ection to the i tem(s) i • The ARD must be less than or equal to 14 days after the determination that a significant has occurred (determination date + 14 calendar days) error in the prior Quarterly .The Z0500B) must be no lat er than 14 days af ter the A RD (ARD MDS c ompletion date ( Item at the signific + 14 ys) and no l ater than 14 days a fter d eter mining th ar da ant error calend rred. occu Tracking Records and Discharge Assessments (A0310F) tracking RA- required records OB and assessments consist of the Entry tra cking r ecor d, the Discharge a ssessments, and the Death in Faci lity tracking r ecord. These include the completion of a select number of MDS ite ms in order to track residents when they enter or leave a f acil ity. re planning. The Dischar They do not include co mpletion of the CAA process and ca ge ms for quali r is orting scharge rep ty monitoring. Entry and di equ assessments include ite ired f or dents. resp ite r esi Swing Bed residents and ssessm the res ent is more adm issions to the hospital bef ore the Ad mission a ident has one or If ntry sessments and E harge as it OBRA Disc completed, the nursing home should continue to subm e until the r esi dent is in the nursing hom e long eno ugh to com plete t he re cords every tim comprehensi ve A dm ission assessm ent. 34 Page 2- October 2018

58 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: he following types ( ng Records and Discharge Assessme nts in clude t acki Item OB RA-required Tr ): A0310F Entry Tracking Record (Item A0310F=01) 07. e two types of entr ies – ad mission and reentry. There ar Item Admission ( A1700=1) Entry t • ing record is coded an Admission ever y ti me a res ident: rack — is ad mitted for the f irst tim e to this f aci lity; or — mitted af ter a d ischarge ret urn not ant ici pated; or is read — mitted af ter a d ischarge ret urn anticipa ted when return was not within 30 days is read of discharg e. Ex amp le (A dmissio n): ollowing a 1. Mr. S. was adm itted to the nursing hom e on February 5, 2011 f stroke. He regai ned most of his function and re turned to his home on March 29, 2011. He was dischar ged return otal knee replacem or a t gery f ent. He not an ticip ated. Five months later, Mr. S. underwent sur returned to the nursing hom e f apy on August 27, 2011. Code the Entry or rehab ilitation ther ecord as fol lows: tracking r for the August 27, 2011 return A0310F = 01 A1600 = 08-27-2011 A1700 = 1 ry (Item A1700 =2) Reent • Entry tracking record is coded Reen try every tim e a person : , — is readmitted to this facility , and was disch arged return an ticipated f rom this facility and ail. ater det retur ned wi thin 30 days of discharge . See Secti on 2.5, Reent ry, f or gre Example (Reentry): 1. Mr . W. was ad mitted to the nursing home on April 11, 2011. Four weeks la ter he becam e sessed him very short of breath d uri ng lunch. The nurse as and noted his lung sounds were return an reathing becam e very labored. He was disch arged r. His b not clea ticipated and admitted to the hospit al on May 9, 2011. On May 18, 2011, Mr. W. returned to the f acility. s follows: Code the Entry t racking record for the May 18, 2011 return, a A0310F = 01 05-18-2011 A1600 = A1700 = 2 35 October 2018 Page 2-

59 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Assessme ent Req uirements and Tips for Entry Track ing Record s: nt Managem The Entry tr acking r eco rd is the first item set co mpleted f or a ll residents. • ntry) pleted ev ery ti me a resident is ad mitted (ad mission) or rea dm itted (ree Must be com • into a nursi ng h om e (or swing bed f aci lity). • Must be com pleted for a resp ite res ident ev ery t im e the resi dent en ters the f acil ity. • pleted wi thin 7 days after the ad mission /reentr y. Must be com th bm itted no la ter than • the 14 Must be su dar calen fter t he entry ( entry date (A16 00) day a + 14 calen dar days). • Required in addition to t he in itia l Ad mission assessment or other OBRA o r PPS assessm ight be requ ired. ents that m • Contains adm inistrative and demogr aphic in formation. • Is a s tand -alone tra cking record. • ent. ssessm mbined with an a May not be co 08. Death in Facility Tracking Record (A0310F=12) pleted when the r esid ent dies in the f acil ity or when on LOA. • Must be com • pleted wi thin 7 days after the resi dent’s d eath, which is r ecorded in item Must be com A2000, Discharge Date (A2000 + 7 calenda r day s). the r • bm itted with in 14 days af ter Must be su esident’s d eath, which is r ecorded in item A2000, Discharge Date (A2000 + 14 calend ar da ys). em • Consists of demographic and adm inistrat ive it s. • M mbined w ay not be co assessme ith any type of nt. Example (Death in Facility): mitted to the nursing hom e for hospice ca re d ue to a t erminal i llne ss on 1. Mr. W. was ad September 9, 2011. He passed away on November 13, 2011. Code the November 13, 2011 Death in Fac ili ty t racki ng record as follows: A0310F = 12 A2000 = 11-13-2011 A2100 = 08 OBRA Discharge Assessments (A0310F) OBRA Discharge a ssess ments consist of dis charge ret urn anti cipa ted and discha rge r eturn not anti ed. cipat 09. Discharge Assessment –Return Not Anticipated (A0310F=10) • the resident is Must be completed when the r esid ent is d ischar ged from the f acil ity and ys. within 30 da lity not expec ted to return to the f aci 36 October 2018 Page 2-

60 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: ge d pleted ( Item Z0500B) within 14 da ys a fter t he dischar Must be com ate (A2000 + 14 • ar da ys). calend Must be su bm itted with in 14 days af ter the MDS co • mpletion date (Z0500B + 14 calendar days). al i tems. ographic, ad ministr ative, and cl inic • Consists of dem If the res ident returns, th e Entry t racking rec ord will be co ded A1700=1, Admission. The • new A the OB RA schedule f or ass essm ents will sta rt with a ent. If dm ission asse ssm resident’s covered by M edica re Part A, the PPS schedule s tarts with a st ay will be Medica re-required 5-d ay scheduled assessm ent or co mbination of the Ad mission and 5- day PPS assessm ent. Ex amp les (Discharge- return not a nticipated): Mr. S. was adm 1. itted to the nursing hom e on February 5, 2011 f ollowing a stroke. He regai s disch arged return not antic ipated to his ho me on ned most of his function and wa March 29, 2011. Code the March 29, 2011 OBRA Discharge as sessm ent as follows: A0310F = 10 A2000 = 03-29-2011 A2100 = 01 2. Mr. K. was transferred from a Medicare-certified bed to a noncertified bed on December 12, Code the December 12, 2013 Discharge ain long term in the facility. 2013 and plans to rem assessment as follows: A0310F=10 A2000=12-12-2013 A2100=2 OBRA –Return Anticipated (A0310F=11) 10. Discharge Assessment Must be com pleted w hen the r • ent is d ischar ged from the f acil ity and the resident is esid to hin 30 days. to the f acil ity wit expected return • For a re sident discharg ed to a hospital or other s etting (such as a res pit e r esident) who acil ity on a rel ativ ely frequent bas is and reentry can be exp ected, comes in and out of the f the resident is disc harg ed return an ticipated unle ss it is known on dischar ge that he or she urn within 30 days. This s will not ret tatus requ ires an Entry tracking r eco rd each time the me the resident resident r lity and a n OBRA Discharge a ssessm ent each ti aci eturns to the f is dischar ged. • M ust be com pleted ( Item Z0500B) within 14 da ys a fter t he dischar ge d ate ( Item A2 000) (i.e., discharge date (A2000) + 14 ca ). lendar days • Must be su bm itted with in 14 days af ter the MDS co mpletion date ( Item Z0500B) (i.e., MDS completion date (Z0500B) + 14 ca lendar days). al i tems. ative, inic and cl • Consists of dem ographic, ad ministr 37 October 2018 Page 2-

61 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • urns to the nursing hom e, the IDT m ust deter mine if criteria are m et When the resident ret (only when the OBR A Admission a ent was com pleted p rior to ssessm for a SCSA ge). char dis If cri teria ar e m et, complete a Signi — in Status as sessm ent. ficant Change — If cri teria are not met, continue wi th the OBRA schedule as established prior to the scharge. resident’s di If a SCSA is not indi • ed and an OBRA assess ment was due while the re sident was in cat the hospi tal, the f aci lity has 13 days af ter r eentry to co mplete the ass essment (this doe s not apply to Adm ent). ission assessm the ident had a prior OBRA Di schar ge assessm ent co mpleted indica • that When a res ting resi dent was expect ed to return (A0310F = 11) to the f aci lity, but la ter lear ned th at the resident will not be r eturning to the f aci lity, t here i s no Federal requirement to inac tiv ate the r s record n or t o co mplete another OBRA Dis charge as sessm ent. Please contac t esident' your Sta te RAI Coordinator f or speci fic State requ irem ents. Example (Discharge -return anticipated): 1. Ms. C. was ad mitted to the nursing home on May 22, 2011. She tripped while a t a r estaurant ad ed and al on May mitted to the hospit with her daughter. She w as disch arged return an ticipat 31, 2011. Code the May 31, 2011 OBRA Discharge ass essm follows: ent as A0310F = 11 A 2000 = 05-31-2011 A2100 = 03 sm ent Management and Tips f or OBRA Discharge Asses Requirements Assessments: acil • esid ent is d ischar ged from the f Must be completed when the r ity (s ee def inition of Discharge on page 2-10). • Must be completed when the r esid ent is ad mitted to an acute care hos pita l. • Must be completed when the r esid ent has a hospital observation s tay g reat er than 24 hours. • Must be completed on a resp ite res ident ev ery t im e the resi dent is disch arged f rom the facil ity. • assessment when requirem May be co mbined with another OBRA- required ents f or all assessm ents are m et. mbined with a PPS Medicare requir ed assessment when requirem ents f or all • May be co assessm ents are m et. • For a n OBRA Disch arge ass essment, the AR D (Item A2 300) is not set prospec tively as with other assess ments. The ARD (Item A2300) f or a n OBRA Disch arge ass essm ent is alwa to the Discharge date ( Item A2000) and ma y be coded on the ass essm ent ys equal any ti me during the OBRA Discharge a ssessm ent completion period (i.e., D ischar ge dat e (A2000) + 14 calenda r days). • The use of the dash, “-”, is appropri ate when the sta ff are unable to de ter mine the lity he f aci may have response to a n ite m, including the inte rview i tems. In som e cases, t 38 October 2018 Page 2-

62 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI already completed s e item s of the asses sment and should record those responses or om may be in the process of c om pleting an assess ment. The f aci lity m ay c om bine the OBRA ent( Disc essm ent with an other as sessm harge ass s) when requi rements f or all as sessments are m et. mplete the OBRA hould co ity s acil Discharge • For u nplanned discharges , the f assessment to the be its ab ilities. st of — An unplanned disch arge include s, f or exam ple: ○ Acute- care transfer of the resident to a hospital or an emergency department in -care admission is order to either stabilize a condition or determine if an acute required based on emergency department evaluation; or Resident unexpectedly leaving the facility against medical advice; or ○ Resident unexpectedly deciding to go home or to another setting (e.g., due to the resident deciding to complete treatment in an alternate setting). ecord have no Nursing hom e bed hold status and opening and c losing of the m edical r • irements. effect on th ese requ The following chart details the sequencing and coding of Tracking records and OBRA Discharge assessments. 39 October 2018 Page 2-

63 Entry, OBRA Discharge, and Reentry Algorithms October 201 CMS’s RAI Version 3.0 Manual 8 CH 2 : Assessments for the RAI Page 2- 40

64 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 2.7 The Care Area Assessment (CAA) Process and Care Plan Completion egula Federal st es to co nduct initi al and periodic assessm ents tions require nurs atute and r ing hom ment in form ation is used to develop, review, and revise t he residents. Th for all their e assess ll be used to provi de serv ices to att ain or m aint ain the r esident’s resident’s plans of care t hat wi ble phy highest pra ental, and psychos ocial w ell-being. ctica sical, m andated M or an accurate sis f ly-m The RAI process, which includes the Federal DS, is the ba ati on and the CAA process provide the e residents. The MDS inform assessment of nursing hom he care plan is form ulated. There are 20 problem- orie nted CAAs, each foundation upon which t based “t rig ger” con ditions that s ign al the n eed f or addi of which includes MDS- al assessm ent tion and rev the trig gered ca re area . Detai led i nformation regarding eac h care area and the CAA iew of initio ns and trigg appear in Chapter 4 of this manual. Chapter 4 also process, including def ers, zing the RAI and CAA process. ailed ation on care plan ns det pm ent utili inform contai ning develo (s) Compl et ion CAA Is req uired f or OBRA -required comprehensive as sessm • ot required f or ents. They are n non- ssments, PP S assessm ents, Disch arge assess ments, or Tra cking comprehensive asse records. Af ter co mpl eting • mprehensive as sess ment, the next st ep is to the MDS portion of the co dent’s s den ms, and needs through use of ngths, proble further i tre tif y and eval uate t he resi the CAA process (d escribed in de tail in Chapter 3, Section V, and Chapter 4 of this urther inves resident-spe cific i ssues not addressed in manual) and through f tigation of any the RAI/CAA process. he sam e date he CAA(s) co mpletion date ( Item V0200B2) mu st be e ith er l ater than or t • T as the MDS co mpletion date ( Item Z0500B). In no event can eith er da te be lat er t han t he established es a s desc ribed in Section 2.6. timefram • It is important to not e that for an Adm ission assessment, the r esident enter s the nurs ing reat hom phys ician -based t e with a set of ment orders. Nursing hom e staff should revie w esident and to identify potent these or ders and begin to assess the r ial c are i ssues/ problems. Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to centered care of the resident that meets professional provide effective and person- In m any cases, inte rven tions to meet the standards of care (42 CFR §483.21(a)). lread y have been implemented to addres s prio resident’s needs will a issues pri or to rity completion of the f inal c are plan. At this tim e, ma ny of the resident’s problems in the 20 care ar eas will have been identifi ed, causes w ill have been consider ed, and a baseline c are plan in However, a f inal CAA(s) rev iew and associ ated docu mentation are s til l itia ted. th mission (admission date plus 13 c day of ad alendar calen dar the 14 required no la ter than days ). • in Chapter 4 of led in formation regarding each CAA and t he CAA pr ocess app ears Detai anual. this m 2- 41 October 2018 Page

65 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH Car e Plan Comp let ion Care plan completion based on the C • or OBRA -required AA process is req uired f ot requir comprehensive asse ssments is n comprehensive assess ed for non- ments. It (Quarterly, SCQA), P PS assessments, Discharge a ssessments, or Tracking records. as required by , However, t he resident’s care plan must be reviewed after each assessment §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Af ter co • eting the MDS and CAA portions of the co mpre hensive a sse ssment, the next mpl to evaluat nform ation gained t hrou gh both assessment processes in order to step is e the i actors, and risk f act ors re lated to the proble ms. iden tify problems, causes, contributing f y, the IDT m ust evaluate the in formation ga ined to develop a care plan t hat Subsequentl address es those findings in the co the resi dent’s goals, preferences, stre ngths, ntext of ms, and nee ds (descr in detai l in Chapter 4 of this m anual). proble ibed her l The care pla Item V0200C2) m ust be eit n co ater than or the sam e date • mpletion date ( mpletion date ( Item V0200B2), but no la ter th an 7 calend as the CAA co fter the ar days a CAA c te. T he MDS co mpletion dat e (I tem Z0 500B) m ust be ear lie r th ompletion da an or the sam plan co mpletion da te. e date as the care an eit her date be l ater than In no event c es as des mefram lished ti tab the es cribed in Section 2.6. • ments, SCSAs, and SCPAs, the process is b asic ally t he sam e as that For Annual assess bed w ith an Admission assessm owever, the c are p lan will descri ent. In these cases, h the CAA(s) mplete f eady be in place. Review of or these alr when the MDS is co ent types should ues tions about the need to modify or continue serv ices assessm raise q lt in eith er the continuance or rev ision of the exis and resu A new care plan ting care plan. does not need to be developed af each Annual assessment, SCSA, or S CPA. ter • R esidents’ preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so . that changes can be reflected in the comprehensive care plan • Detai led in formation regarding the care planning process appears in Chapter 4 of th is manual. 2.8 The Skilled Nursing Facility Medicare Prospective Payment System Assessment Schedule urs Skilled n ing f acil ities (SNFs) must assess the c lin ical con dition of benef ici aries by com pleting or the MDS as each Medic are resident r ecei ving Pa rt A SNF -level ca re f ment for sess rei mbursement under the SNF PPS. In addition to the Medic are- requ ired assess ments, the SNF must also com plete the OB RA assess ments. All requirem ents f or the OBRA assess ments ap ply s. to the M care- requ ired assessments, such as completion and subm ission ti me frame edi Asses sment Wi ndow Each of the Medica re-required scheduled ass essments has defined days within which the uired he ARD on the to set t ity is req Assessm ent Ref erence Date (ARD) m ust be set. The f acil 2- 42 October 2018 Page

66 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH MDS f in t he f acil ity so ftware wit hin the appropr iate t imeframe of the ass essm ent or m itself or pleted. F day sched mple, the ARD f or the Medicar e-req uired 5- c om uled type being or exa ust be set the PPS assess hrough 8. T imeliness of ent m ment is de fined by assessm on days 1 t ting an within the pre scribed ARD wi ndow. See Scheduled M edicar e PPS selec ARD ents chart below for the a llowed ARDs for each of t he Medi care-requi red as Assessm sessments and other ent in formation. a ssessm lone Change of Therapy OMRA (CO dal one End of T herapy When coding a standa T), a stan ities tandalone St OT), or a s OT), f acil art of must set t he ARD f or OMRA (E Therapy OMRA (S essm ent f or a day within the a the ass RD window for tha t asse ssment type, but m ay do llowable A so no m fter t he window has passed. ore than two days a curre irst day Medicare Part A cov The f or the of nt s tay is consi der ed day 1 f or PPS erage f t he f the age is Medicare Part A cover of assessm ent scheduling purposes. In m ost cases, irst day eficiary date of reen try. However, the re ar e s itu ations in which the M edica re ben mission or ad quali fy f or Part A s ervices at a l may ate. See Chapter 6, Section 6.7, f or more de tailed ater d information. Grac e Days There m ay be sit uatio ns when an as RN assessor, a ment might be de layed (e.g., illn ess of sess re needed to high volum e of assessm ents due a t approxi mately the sam e ti me) or ad di tional days a re therapy or ations ot her t more f ully captu or these situ a llowed f reat ments. There fore, CMS has are- by de num ber of grace days f or each Medic are ass essm ent. For exa mple, the Medic fining a required 5- Day ARD can be extended 1 to 3 gra ce days (i.e., da ys 6 to 8). T he use of grace da ys allows c lini cal f lexib ility in set ting ARDs. See cha rt below f or t he allowed grace da ys f or each of the schedu led Medic are-requi red as sess ments. G race da ys a re not appl ied to unscheduled ments. PS Assess Medica re P 2-43 October 2018 Page

67 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI ed Me dicare PP S Asses sments Sch uled ired s tandard The Medica essm ent schedule in clude s 5 -day, 14- day, 30 -day, 60-day, re-r equ ass day scheduled ass ess ments, each with a p redet ermined tim e period for set ting t he ARD and 90- sessment. for that as plete the Medi care-requir ed as sess ments according to the following The SNF provider must com assure co mplian ce with t he SNF PPS requirem ents. schedule to Medicare MDS Applicable Standard Assessment Reference Reason for Assessment Assessment Scheduled Date Medicare Reference Date (A0310B code) Assessment Type Grace Days+ Payment Days^ 01 Days 1-5 6-8 1 through 14 5-day day 02 Days 1 3-14 15-18 15 through 30 14- 7-29 30- day 03 Days 2 31 through 60 30-33 7-59 60- 04 Days 5 day 60-63 61 through 90 05 90- day Days 8 7-89 90-93 91 through 100 +Grace Days: a specific number of days that can be added to the ARD window without penalty. ^Applicable Standard Medicare Payment Days may vary when assessment types are combined. For example, when a provider combines an unscheduled assessment, such as a Significant Change in Status Assessment (SCSA) , with a scheduled assessment, such as a 30 -day Medicare- required assessment, the new resource utilization group (RUG) , the new RUG would take would take effect on the ARD of the assessment. If the ARD of this assessment was day 28 effect on day 28 of the stay. The exception would be if the ARD fell within the grace days. In that case, the new RUG would be effective on the first day of the regular payment period. For example, if the ARD of an unscheduled assessm ent combined with the 60 -day assessment , was day 62, the new RUG would take effect on day 61. ed sch Medicare PP S Assessments Un uled e s ituations when a SNF provider must com plete an a ssessment outside of the standard There ar Medica re-required as sessm ents. These asse ssments are known as unscheduled scheduled When indic ents. ust co ated, a prov ider m assessm mplete the following unscheduled as sessm ents: nscheduled 1. Signi ficant Change in Status Assess ment ( for swing bed providers this u assessm ent i s called the Swing Bed Clinic al Change Asses sment) (se e S ection 2.6). 2. Signi ficant Correction to Prior Comprehensive Assessment (see Section 2.6). A) (see Section 2.9). 3. Start of T her apy Other M edicare Required Asse ssment ( SOT -OMR 4. End of Therapy Other M edicare Required As sessment (EOT - OMRA) (see S ection 2.9). 5. Change of Therapy Oth er Medica re Required As sessment ( COT -OMR A) (see S ection 2.9). A Medicare unscheduled assessm ent in a sched uled assessment window cannot be followed by ents the sched ule d assessm ent l ater in th at window—the two assessm ust be co m mbined with an ARD appr ate to the unscheduled assessm ent. If a schedu led assess ment has been co mpleted opri and an unsc heduled as sessm ent f alls in th at asses sm ent win dow, the unscheduled as sessm ent may supersede the sched uled ass essment and the paym ent m ay be modified unti l the next or 6.4) and Section 2.10 below f unscheduled or schedule d assessm ent. See Chap ter 6 (Se ction ls. complete detai 2- 44 October 2018 Page

68 CMS’s RAI Version 3.0 Manual Assessments for the RAI CH 2: Tracki ng Rec ords and Disch ar ge Assessmen ts Re porti ng ssments reporting are re Tracking cords and dis charge a sse re quired on all residents in t he SNF pact essments do not im scharge ass and swing bed f acil iti es. Tracking records and st andalone Di paym ent. Part A PPS Discharge Assessment (A0310H) The Part A PPS Discharge assessment contains data elements used to calculate current and future Skilled Nursing F acility Q uality Reporting P rogram (SNF QRP) quality measures under the IMPACT Act . The IMPACT Act directs the Secretary to specify quality measures on which acute care ( post- PAC ) providers (which includes SNFs) are required to submit standardized patient assessment data. Section 1899B(2)(b)(1)(A)(B) of the Act delineates that patient assessment data must be submitted with respect to a resident’s admission into and discharge from a SNF setting. • Per current requirements, the OBRA Discharge assessment is used when the resident is physically discharged from the facility. Th e Part A PPS Discharge assessment is remains Part A stay ends, but the resident in completed when a resident ’s Medicare . Item A0310H, “Is this a Part A PPS Discharge Assessment?” identifies the facility whether or not the discharge is a Part A PPS Discharge assessment for the purposes of the SNF QRP (see Chapter 3, Section A for further details and coding instructions). The Part A PPS Discharge assessment can also be combined with the OBRA Discharge assessment when a resident receiving services under SNF Part A PPS has a Discharge on the day of or one day after the End Date of Most Recent Date (A2000) that occurs Medicare Stay (A2400C), because in this instance, both the OBRA and Part A PPS Discharge assessments would be required . Discharge Assessment (A0310H = 1): Part A PPS • Must be completed when the resident’s Medicare Part A stay ends, but the resident remains in the facility (i.e., is not physically discharged from the f acil ity). • For the Part A PPS Discharge ass essment, the AR D (Item A2 300) is not set prospec tively arge as w ith other assess ments. The ARD (A2300) f or a standalone Part A PPS Disch ass to the End Date of the Most Recent Medicare Stay (A2400C). ys equal essm ent is alwa ssessm ent completion essm ent any ti me during the a on the ass y be coded The ARD ma period (i.e., End Date of Most Recent Medicare Stay (A2400C) + 14 calenda r days) . • If the resident’s Medicare Part A stay ends and the resident is physically discharged from the facility, an OBRA Discharge assessment is required. • If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the Discharge Date (A2000), the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000). The Part A PPS Discharge assessment may be co mbined ments or all assess with most PPS and OBRA- required assessments when requirem ents f et (please see Section 2.11 Combining Medicare Assessments and OBRA are m Assessments). 2- 45 October 2018 Page

69 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH he End Date of Most Recent fter t ys a • Must be c om pleted ( Item Z0500B) within 14 da ys). Medicare Stay (A2400C + 14 calend ar da fter mpletion date (Z0500B + 14 calendar the MDS co • Must be su bm itted with in 14 days a days). ministr • Consists of de mographic, ad ative, and c linic al i tems. tay ends and the resident subsequently returns to a If the resident’s Medicare Part A s • skilled level of care and Medicare Part A benefits resume, the Medicare schedule starts -Day PPS assessment. again with a 5 ollowing chart s The f umm arizes t he Medi care-requi red scheduled and unscheduled assessm ents, sse ssments: tracking r ecords, and di scharge a 2-46 October 2018 Page

70 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI Medicare Scheduled and Unscheduled MDS Assessment s, Tracking Records, and Discharge Assessment Reporting Schedule for SNFs and Swing Bed Facilities Assessment Grace Days Assessment Billing Cycle Reference Date Allowed (ARD) Can be Set Type/Item Set ARD Can Also Used by the on Any of Required for be Set on These Business ARD Medicare Following Days Days Window Office Special Comment 5-day Sets payment -8 Days 1 -5 6-8 Days 1 3 for • See Section 2.1 instructions involving rate for days A0310B = 01 1-14 beneficiaries who transfer or expire day 8 or earlier. • CAAs must be completed only if the Medicare 5 - day scheduled assessment is dually coded as an OBRA Admission or Annual assessment, SCSA or SCPA. 18 Sets payment 13-18 Days 14- day 15- Days 13-14 CAAs must be completed • = 02 A0310B rate for days only if the 14-day 30 15- assessment is dually coded as an OBRA Admission or Annual assessment, SCSA or SCPA. • Grace days do not apply day when the 14- scheduled assessment is dually coded as an OBRA Admission. 30- Sets payment Days 27-29 30- day Days 27-33 33 = 03 A0310B rate for days 31- 60 Days 5 60- Sets payment 7-63 day 63 60- Days 5 7-59 = 04 A0310B rate for days 61- 90 Sets payment 87-93 93 Days 90- day 90- Days 8 7-89 If combined with the • A0310B = 05 OBRA Quarterly rate for days 91- 100 assessment the completion date requirements for the OBRA Quarterly assessment must also be met. (continued) 2-47 October 2018 Page

71 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI Medicare Scheduled and Unscheduled MDS Assessment s, Tracking Records, and Discharge Assessment Reporting Schedule for SNFs and Swing Bed Facilities (cont.) Grace Days Assessment Assessment ARD Can Reference Date Billing Cycle Allowed (ARD) Can be Set Type/Item Set Also be Set on These Required for on Any of Used by the ARD Following Days Days Medicare Window Business Office Special Comment Start of Therapy Modifies N/A N/A • 5–7 days after the Voluntary assessment • start of therapy Other Medicare- used to establish a payment rate starting on the required Assessment Rehabilitation Plus The day of the • date of the first (OMRA) Extensive Services or first therapy Rehabilitation RUG. = 1 A0310C therapy evaluation counts evaluation as day 1 End of Therapy N/A N/A Modifies • Not required if the • 1–3 days after all OMRA A0310C = 2 payment rate therapy ( resident has been Physical starting on the determined to no PT Therapy ( ), day after the Occupational longer meet Medicare skilled level of care. ), OT Therapy ( latest therapy end date Speech Language • - Establishes a new non SLP )) Pathology ( therapy RUG services are Classification. discontinued. Only required for • • The first non- patients who are therapy day counts classified into as day 1. Rehabilitation Plus Extensive Services or Rehabilitation RUG on most recent PPS asse ssment. • For circumstances when an End of Therapy with Resumption option would be used, See Section 2.9. Change of Therapy Modifies N/A N/A if the • • Day 7 of the COT Required only observation period OMRA payment rate intensity of therapy on starting during the 7 -day look A0310C = 4 Day 1 of that back period would COT change the RUG ssification cla category observation period and of the most recent PPS continues for Assessment the remainder • Establishes a new RUG of the current classification payment period, unless the payment is modified by a subsequent COT OMRA or other scheduled or unscheduled PPS assessment (continued) 2-48 October 2018 Page

72 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI Medicare Scheduled and Unscheduled MDS Assessment s, Tracking Records, and Reporting Schedule for SNFs and Swing Bed Facilities (cont.) Discharge Assessment Grace Days Assessment Assessment ARD Can Reference Date Billing Cycle Used Allowed (ARD) Can be Set Also be Set Type/Item Set Required for on These on Any of Following ARD by the Business Days Days Medicare Window Office Special Comment Completed by the end Modifies payment N/A N/A Significant Change in May establish a new • RUG Classification. Assessment of the 14th calendar Status rate effective with day after determination (SCSA) A0310A = the ARD when not 04 that a significant combined with change has occurred. another assessment* Modifies payment Completed by the end N/A N/A Swing Bed Clinical May establish a new • rate effective with Assessment of the 14th calendar Change RUG Classification. = 1 (CCA) A0310D day after determination the ARD when not that a clinical change combined with has occurred. another assessment* Significant Completed by the end N/A Modifies N/A May establish a new • RUG Classification. Correction to Prior of the 14th calendar payment rate Comprehensive after identification day effective with of a significant, Assessment (SCPA) the ARD when = 05 A0310A uncorrected error in not combined prior comprehensive with another assessment. assessment* Entry tracking record N/A N/A N/A N/A • May not be combined A0310F = 01 with another assessment N/A N/A N/A for the Must be set Discharge OBRA • May be combined day of discharge Assessment with another assessment when the A0310F = 10 or 11 date of discharge is the ARD of the Medicare-required assessment and the resident is physically discharged from the facility . N/A Must be set for the Part A PPS N/A N/A • Completed when the Discharge resident’s Medicare last day of the Assessment Part A stay ends, but Medicare Part A Stay (A2400C) esident remains the r A0310H = 1 in the facility, or can be combined with an OBRA Discharge assessment if the Part A stay ends on the same day or the day before the resident’s Discharge Date (A2000). Death in facility May not be combined N/A N/A N/A N/A with another assessment . record tracking A0310F = 12 *NOTE: When SCSA, SCPA, and CCA are combined with another assessment, payment rate may not be effective required assessment with a Significant Change -day Medicare- the 30 on the ARD. For example, a provider combines in Status assessment with an ARD of day 33, a grace day, payment rate would become effective on day 31, not day 33. See Chapter 6, Section 6.4. October 2018 Page 2-49

73 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 2.9 MDS Medicare Assessments for SNFs cted to The MDS has been con OBRA Reasons f or Assessment and the SNF PPS identi stru fy the the assess tem 0310A and A0310B respe ctiv ely. If ent in I ment is b eing or Assessm Reasons f s A edicar e r eimb urse ment, the Medic are Reason f or Assessm ent must be co ded in I tem used f or M Reason f A0310B. Th ent is descri bed earl ier in th is section whi le t he e OBRA or Assessm PS assessme vider m ibed below. A SNF pro re P ay co mbine assessments to Medica nts are descr re req edica ments. W hen co mbining assess ments, al l co mpletion meet both OBRA and M uire nes and other r equ irements for both types of assessm ents must be m et. If al l re quire ments deadli ssm ents m ust be co mpleted separ ately. The rel atio nship betwee n OB RA cannot be met, the asse e assess ments are discu ore detai l in Se ctions 2.11 and 2.12. and Medicar ssed below and in m A Stay led hedu ts for a Me dicare Part Assessm PPS Sc en Medicare- required 5 -Day Scheduled Assessment 01. ARD (Item A2300) must be set on days 1 through 5 of the Part A SNF covered s tay. • ARD m ay be extended up to day 8 if using the de signa ted gr ace days. • ARD pleted ( Item Z0500B) within 14 da ys a fter t he ARD ( • + 14 days). Must be com ent from days 1 through 14 of the stay, as • long as the re sident m eets all Authorizes paym or Part A SNF -l evel s ervi ces. criteria f ent Su to the QIES Assessm ted in ctronical • Must be su bm itted ele bmission and ly and accep Processing (ASAP) system ter co mpletion ( Item Z0500B) (co mplet ion + within 14 days af 14 days). • If co mbined with the OBRA Adm issi on assessment, the a sse ssm must be co mpleted ent by the end of day 14 of ad mission (admission date plus 13 c alendar days ). • Is the fir st Medica re-required as sessm ent to be co mpleted when the resident is f irst admitted f or SNF Part A stay. Is the fir st Medica • sessm ent to be co mpleted when the Part A resident is r e- re-required as admitted to t he f acil ity f ollowing a di scharge ass essment – re turn not antic ipated or if t he turn resident r ter a discharge assess ment -re eturns more than 30 days af an ticip ated. re • If a resi dent goes f rom Medica Medica Advantage to re P art A, the Me dica re PPS schedule m ust st ver with a 5 -da y PPS assess ment as the resident i s now beginning a art o re P Medica art A stay. Medicare- required 14 -Day Scheduled Assessment 02. A SNF covered s A2300) must be set on days 13 through 14 of the Part • tay. ARD (Item • ay b e extended up to day 18 if using the d esign ated g race days. ARD m • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD ( ARD + 14 days). • Authorizes paym ent from days 15 through 30 of the stay, as long as all t he covera ge criteria f or Part A SNF -l evel s ervi ces continue to be m et. ctronical • Must be su bm itted ele ly and accep ted in to the QIES ASAP system within 14 Z0500 + 14 days). mpletion B) (co days a fter completion (It em 2- 50 October 2018 Page

74 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • issi on assessment, the a sse ssm ent must be co mpleted If combined with the OBRA Adm RD. ys may not be used when setting the A by the end of day 14 of admission and grace da 03. Medicare- required 30-Day Scheduled Assessment ARD (Item • tay. A2300) must be set on days 27 through 29 of the Part A SNF covered s • ARD m ay b e ex tended up to day 33 if using the d esign ated g race days. fter t • pleted ( Item Z0500B) within 14 da ys a Must be com he ARD ( ARD + 14 days). • Authorizes paym ent from days 31 through 60 of the stay, as long as all t he covera ge criteria f or Part A SNF ervi ces continue to be m et. -l evel s within 14 bm itted ele ctronical • accep ted in to the QIES ASAP system Must be su ly and days a fter completion (It em Z0500 B) (co mpletion + 14 days). 04. Medicare- required 60-Day Scheduled Assessment • ARD (Item A2300) must be set on days 57 thro ugh 59 of the Part A SNF covered s tay. • ARD m ay b e extended up to day 63 if using the d esign ated g race days. ys a • Must be com pleted ( Item Z0500B) within 14 da fter t he ARD ( ARD + 14 days). long as ge he covera all t • Authorizes paym ent from days 61 through 90 of the stay, as criteria f or Part A SNF ervi ces continue to be m et. -l evel s within 14 bm itted ele ctronical • accep ted in to the QIES ASAP system Must be su ly and days a fter completion (It em Z0500 B) (co mpletion + 14 days). 05. Medicare- required 90 -Day Scheduled Assessment • AR D (Item A2300) must be set on days 87 through 89 of the Part A SNF covered s tay. • ARD m ay b e extended up to day 93 if using the d esign ated g race days. fter t • Must be com pleted ( Item Z0500B) within 14 da ys a he ARD ( ARD + 14 days). • Authorizes paym ent from days 91 through 100 of the stay, a s long as a ll the cov erage criteria f or Part A SNF ervi ces continue to be m et. -l evel s within 14 bm itted ele ctronical • accep ted in to the QIES ASAP system Must be su ly and days a fter completion (It em Z0500 B) (co mpletion + 14 days). PPS Un sche duled Assessme nts for a Me dicare Part A Stay 07. Assessments Used for PPS Unscheduled There ar e s everal un scheduled assessm ent types that m ay be required to be co mpleted during a resident’s P art A SNF covered s tay. Start of Th erapy (SOT) OM RA Optional. • 2- 51 October 2018 Page

75 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • pleted only to c las sif y a resi dent into a RUG -IV Rehabil itation Plus Extensive Com -IV clas Services or Rehabil lita tion Plus sif ication is not a Re itation group. If the RUG habi itation (ther ent will n group, the a ssessm ces or a Rehabil ot be Extensive S apy) ervi are bi lling. CMS and cannot be used for Medic accep ted by Com pleted only if • esident is n ot a lready cla ssi fied i nto a RUG- IV R ehabil ita tion Plus the r ervi ehabi lita tion group. Extensive S ces or R A2300) must be set on days 5 –7 after the s tart of therapy ( Item O0400A5 or • ARD (Item whichever is the ea rliest date) w ith the excep tion of the Short O0400B5 or O0400C5, Stay Assessm ent (see Chapter 6, S liest th erapy ev alua tion ection 6.4). The date of the ear ed as day 1 when deter mining the ARD for the S of Therapy OMRA, is count tart if tre dless regar atment is provided or not on that day. May be co mbined with scheduled PP S assessm ents. • ces s An SOT ary if rehab ili tation servi OMRA is not necess tart w ithin the ARD win dow • cluding grace day s) of the 5 -day a ssessm ent, since t (in apy ra te will be paid s tarting he ther Day 1 of the SNF stay. may not precede the ARD of f irst sch eduled PPS assess ment of the Medicar e • The ARD 5-day as sessm ent). stay ( ent i mple if the 5 -day assessm For exa s per form ed on Day 8 and an SOT is perform ed — D for the SOT would be Day 8 as well. dow, the AR at win in th • M ust be com Item Z0500B) within 14 da ys a fter t he ARD ( ARD + 14 days). pleted ( Estab lishes a RUG • fication and Medicar e pay ment (see Chapter 6, Section 6.4 -IV classi for polici es on determ ining RUG -IV pay ment), which begins on the day t herapy s ta rted. • Must be su bm itted ele ctronical ly and accep ted in to the QIES ASAP system within 14 days a em Z0500 B) (co mpletion + 14 days). fter completion (It End of Therapy (EOT) OMRA • Required when the r esi dent was clas sified in a R UG- IV Re habi litation P lus Exten sive Services or Rehabil itation group and continue s t o need Part A SNF -level servi ces aft er inuation of al the plan ned or unplanned discont l r ehabi lita tion therapies for thre e or m ore consecu tive days. ARD (Item ter al l re habili tation the rapies have A2300) must be set on day 1, 2, or 3 af • or a ny reason (I tem O0400A6 or O0400B6 or O0400C6, whichever is ntinued f been disco the l he las t day on which ther apy tr eatment was f urn ished is consi dered day 0 atest). T when determ ining the ARD for the End of Therapy OMRA. Day 1 is the f irst day a fter the l ast t her apy tre atment was provided whether therapy was s cheduled or n ot sched uled for that day. For exa mple: If the res — from all therapy se rvices on Tuesday, day 1 is ident was discharged Wednesday. — If the res ident was discharged f rom all therapy se rvices on Friday, Day 1 would be Saturday. — If the res ident re ceived therapy Fri day, was not scheduled for therapy on Saturday or used erapy for Monday, Day 1 would be Saturday. Sunday and ref th 2- 52 October 2018 Page

76 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • For purposes of determining when an EOT OMRA must be completed, a treatment day is defined exactly the same way as in Chapter 3, Section O, 15 minutes of therapy a day. If es of therapy in a day, it is not coded on the MDS a resident receives less than 15 minut and it cannot be considered a day of therapy. set f mbined with a ent. In such cases, t he i tem ed PPS assessm or the May be co • ny schedul d. scheduled a ssessm ent should be use of the f or the End of m ay not pre cede t he ARD Therapy OMRA first sc heduled The ARD • the Medica re st ay (5 -day as sessment). PPS assessm ent of For exa the 5 -day assessm ent is co mplet ed on day 8 and an EOT is com pleted — mple: if dow, the A or the EOT should be Day 8 as well. at win RD f in th Must be c om pleted ( Item Z0500B) within 14 da ys a fter t he ARD ( • + 14 days). ARD a new non- therapy RUG clas sificat Establishes care pay ment rate ( Item • ion and Medi hich begi ns t he day a fter the l ast day of therapy tr Z0150A), w ment re gardle ss of day eat selec or ARD. ted f Must be su itted ele ctronica lly to t he QIES A SAP system a nd accep ted into t he QIES • bm fter com pletion ( Item Z050 0B) (co mpletion + 14 days). ASAP system within 14 days a In cases wh ere a resident is disc harg ed f rom the SNF on or pr ior to t he t hird consec ut ive • issed therapy se rvices, then no EOT is required. M ore pr ecis ely, in cases w here the day of m nsecu ded f or to t he th ird co A2000 is on or pri tive day of m issed therapy date co or Item then no EOT OM RA is requ ired. If a SNF services, om plete the EOT OMRA chooses to c in this s tion, they m ay co mbine the E itua RA with the dis charge assess ment. OT OM st d ate used to code the d fit, that is • In cases wh ere the la A bene ay of the Medicar e Part A2400C on the MDS, is prior t hird cons ecutive day of missed ther apy servi ces, to the requi t he date lis ted in A2400C is on or a fter the t hird then no EOT OMRA is red. If tive day of m issed therapy se rvices, then consecu MRA would b e requ ired. an EOT O • In cases wh ere the date used to code A2400C is equal to the date used to c ode A2000, that is cas es where the di scharge f rom Medicare Part A is the sa me day as the di schar ge t he th from ity, and t his date is on or pri or to acil ird cons ecutive day of missed the f therapy s ervices, then no EOT OM RA is requ ired. Faci liti es m ay choose to c om bine the ned f EOT OM ge as sess ment under the rul es outli RA with the dischar or such combinations in Chapt er 2 of the MDS RAI manual. more cons • If the EOT OMRA is per formed be cause th ree or therapy were ecutive days of missed , and it is det the rapy will re sum e, there a re th ree op tions f or ermined that completion: Com plete only the EOT OMRA and keep the re sident in a n on- Rehabi lita tion RUG 1. ory un scheduled PPS assess categ ment is co mplete d. For exa mple: til the next • Mr. K. was dischar ged f rom all ther apy servi ces on Day 22 of his SNF stay. The EOT OM RA was per formed on D ay 24 of his SNF stay and clas sified i nto HD1. Pa t HD1 until the 30- day ass essm ent was co mpleted. At that yment continued a point, t herap y resu med (with a new t herapy ev aluatio n) and t he resi dent was clas nto RVB. sified i 2. In cases wh ore than 5 erapy re sumes af ter an EOT O MRA is per formed and m ere th ast day of the l vi ded, or t herapy pro ed since consecu tive calend ar da ys have pass 2-53 October 2018 Page

77 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI therapy s resu me at t he sam e RU G-IV thera py clas sification level that ervices w ill not t o the EOT OMRA, an RA is requ ffect prior ired to cl assi fy the had been in e SOT OM ck into a RUG py group and a new therap y evalu ation is req uired resident ba -IV thera exam ple: Mr. G. who had been c lassi fied i nto RVX did n ot re ceive as well. For therapy on Sat urday and Sunday. He also m Monday be cause his issed therapy on me to visit, on Tuesday he m apy due to a doctor ’s ap point ment and family ca issed ther ednesday. An EOT O MRA was per formed on Monday refused t herapy on W fying him classi he ES2 non- therapy RUG. He m issed 5 consecu tive calend ar into t da ys of therap y. A new therapy eval uation was c ompleted and he resu med therapy services on T hursday. An SOT O MRA was then co mpleted and Mr. G. was placed back into t he RVX therapy RUG category. lassi fied in to RHC did not re ceive t herapy on M onday, • Mrs. B., who had been c nd W ednesday because of an in fectio n, and it was deter mined t Tuesday, a hat she would be able to s ain on Thursda y. An EOT OMRA was co mpleted tart therapy ag or the three day s she did not have th erapy with a non- therapy RUG to pay f classi ficat ion of HC2. It was deter mined t hat Mrs. B. w ould not be able to resu me the rapy at t ame R UG-IV therapy clas sificat ion, a nd an SOT OMRA was he s ace her i nto the R MB RUG -IV therapy c ategory. A new therapy completed to pl eval uation was r equired. 3. In cases where th erapy re sumes af ter the EOT O MRA is per formed and the st mption of therapy date i s no m ore than 5 c onsecu tive ca lendar days a fter the la resu med at t have resu ices ame R UG-IV he s day of ther apy provided, and the t he rapy serv clas sificat and with the s ame ther apy p lan of care t hat had been i n e ffect ion level, to the ption (EOT RA, an End of Therapy OMRA with Res um prior -R) may EOT OM mpleted. For Exa be co mple: Mrs. A. who was in RVL did not r • ive th erapy on Saturday and Sunday because ece the f aci lity did not provi de weekend servi ces and she m issed therapy on Monday because of a doctor ppoint ment, but resum ed therapy Tues day. The IDT ’s a mined t deter -IV the rapy clas sificat ion level did not c hange a s she had hat her RUG not had any signi ficant c lin ical cha nges during t he lapsed t herapy days. An EOT - R was com and M rs. A was placed into ES3 f or the thre e days she did not pleted rece ive th erapy. On Tuesday, Mrs. A. was placed back i nto RVL, whi ch was the tion of same therapy RUG gro up she was in prior to the discont inua therapy. A new therapy evalu uired. ation was not req If t he EOT O ed in the Q IES AS AP when the rapy NOTE: MRA has not been accept mes, code the EOT -R ite ms (O 0450A and O0450B) on the assess ment and subm it t he resu If t he EOT O -R ite ms has been accep ted i nto the QI ES MRA without the EOT record. m, then subm it a RA with the onl odi fication requ est f or th at EOT OM ASAP syste y m changes b eing the co mple tion of the EOT -R ite ms and check X0900E to indica te th at the the Res reason f ficat ion i s the ad dition of odi um ption of Therapy dat e. or m NOTE: When an EOT -R is co mplet ed, the Ther apy Start D ate (O0400A5, O0400B5, and O0400C5) on the next P PS assessm ent is the sam e as the Th erapy Sta rt Date on t he EOT - 0400B6, and O0400C6) R. If therapy is ongoing, the Therapy End Date (O0400A6, O ill ed out with would be f dashes. 2-54 October 2018 Page

78 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: In cases wh in one payment period and the r esumption date is en the the rapy end date is ment period, the f given on the lity should bil l the non- therapy RUG t pay in the nex aci RA beginning the day afte last da y of therapy tre atment and begin bi lli ng EOT OM r the erapy RUG that was in e ffect prior to the EOT OM RA beginning on the day t hat the th res therapy B). If the resumption of therapy occurs a ft er the n ext b illing umed (O0450 arted, y a future his th erapy RUG should be used until modif ied b period has st then t d assessm scheduled or unschedule ent. For exa • dent m isses ther apy on Days 11, 12, and 13 and resum es mple, a resi therapy on Day 15. In t his case the f acil ity sho uld bil l the n on-ther apy RUG f or Days 11, 12, 13, and 14 and on Day 15 the f aci ll the RUG that was lity should bi ffect pr in e ior to the EOT. Change of Therapy (COT) OMRA Required when the r esi dent was r ece iving a • fficient leve l of rehabilit ati on th erapy to su qua lify f or an U ltra High, Very High, High, Medium, or Lo w R eha bilita ti on category and when the intensity of th erapy (as indi cated by the tota l reimbursable th era py minutes (RTM) de her th erapy qualifie rs s uch as nu mbe r of therapy days and livered, and ot disci plin es providing th erapy) c han ges to such a degree that it would no l onger re fle ct the RUG- IV classi fication and paym ent assigned for a given SNF resident based on the most are paym sment used for Medic ent. recent asses • AR D is set for Day 7 of a COT observation pe observation periods a re riod. The COT succes sive 7-day windows with the first obse rvation p eriod beginning on the day ecent s following the ARD set for the most r heduled PPS assess ment, cheduled or unsc except f or a n EOT -R assess ment (s ee below). For exam ple: — If the ARD for a pat ien t’s 30- day as sess ment is set for day 30, and ther e are no intervening assessments, then the COT observation period ends on Day 37. — If the ARD for the pa tient’s m ost rece hether the COT was comp leted or nt COT (w not) was Day 37, the next COT observation period would end on Day 44. • In cases wh ere the la st PPS Asses sm ent was an E OT -R, the end of the f irst COT observation period is Day 7 a fter the Res umption of Therapy date (O045 0B) on the E OT - an the ARD. R, rather th unted as day 1 when The resu mption of therap y date is co deter mining Day 7 of the COT observation pe ple: riod. For exam -R is set f or day 35 and the resu mption date is the equival ent — If the ARD for an EOT of day 37, then the COT observation period ends on day 43. An evalua • ity f or a COT OMR A (that is, a n evalu ation of the ther apy tion of the necess inten sity, as descri bed above) m ust be co mpleted af ter the C OT observation period is over. • The COT would be com pleted if the patie th erapy i ntens ity, as described above, has nt’s changed to c lassi fy t he r esident into a higher or lower RUG c ategory. For exa mple: If a f acil ity s ets t he ARD for its 14-day assessment to day 14, Day 1 for purposes of the COT period would be Day 15 of the SNF stay, and the fa cility would be requ ired or t sting of Day he week consi to re view t he ther apy se rvices pro vided to the pat ient f 2- 55 October 2018 Page

79 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 15 through 21. The A RA would then be set f or Day 21, if the RD f or the COT OM to det facil xample, the total RTM h as changed s uch that the ermine that, f ity were or e rom that f ound on the 14- day UG classi resident’s R fication would change f assu ming no int ervening assess ments). If the t assessm ult ent ( ot al RTM would not res fication the rapy categ ory quali fiers have in a RUG classi change, and all other COT nt with consiste t’s curre nt RUG classi fication, then the the pa remained tien om pleted. OMRA would not be c If Day 7 of • erva tion pe riod f alls within the ARD window of a scheduled P PS t he COT obs assessm ma y choose to co mplete the scheduled PPS a ssessm ent alone by ent, the SNF ting t the scheduled P PS assessme nt f or an a llowable day t hat is on or prior set he ARD of Day 7 of the COT observa tion period. Thi s e ffectively r esets the COT observa tion to he 7 days f owing that sc period to t heduled PPS a ssessm ent ARD. Alte rnativ ely, the oll ment f m om bine the COT OM RA and schedu led assess SNF ollowing the ay choose to c instru ctions discussed in Section 2.10. Day 7 ior to on or pr • the COT of In cases wh ere a resident is disc harg ed f rom the SNF observa tion period, then MRA is requi red. More pr ecis ely, in c ases where t he no COT O for Item A2 000 is on or prior to Day 7 of the C OT observa tion period, th en no date coded COT OMR A is requ ired. If a SNF chooses to c om plete the COT OMR A in this s ituation, they m RA with the OBRA D ischarge as sessment. mbine the COT OM ay co In cases where the last day of the Medicare Part A benefit (the date used to code A2400C on the MDS) is prior to Day 7 of the COT observation period, then no COT OMRA is required. If the date listed in A2400C is on or af ter Day 7 of the COT observation period, then a COT OMRA would be required if all other conditions are met. If the date listed in A2400C is on Day 7 of the COT observation period, then the SNF must complete both sessment. These assessments must be the COT OMRA and the Part A PPS Discharge As completed separately . Finally, in cases where the date used to code A2400C is equal to the date used to code A2000—that is, cases where the discharge from Medicare Part A is the same day as the discharge from the facility — and this date is on or prior to Day 7 of the COT observation period, then no COT OMRA is required. Facilities may choose to combine the COT Discharge assessment under the rules outlined for such OMRA with the OBRA combination in this chapter. ARD of • The COT A RD m ay not precede the the f irst sched uled or unsche duled PPS UG- assessm ent of the Medi care s tay us ed to es tabl ish the pa tien t’s initial R apy IV ther clas sificat . ion in a Medicare Part A SNF stay • Except as described below, a COT OMRA may only be completed when a resident is currently classified into a RUG -IV therapy group (regardless of whether or not the resident is classified into this group for payment), based on the resident’s most recent asses sment used for payment . • The COT OMRA may be completed when a resident is not currently classified into a RUG- IV therapy group, but only if both of the following conditions are met : assessment -IV therapy group on a prior 1. Resident has been classified into a RUG , and during the resident’s current Medicare Part A stay 2-56 October 2018 Page

80 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI No discontinuation of therapy services (planned or unplanned discontinuation of all 2. rehabilitation therapies for three or more consecutive days) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into -IV group and the ARD of the COT OMRA that his/her current non- therapy RUG reclassified the residen -IV therapy group. t into a RUG Under these circumstances, completing the COT OMRA to reclassify t he resident into a therapy group may be considered optional. Additionally, the COT OMRA which classifies a resident into a non -therapy group or the COT OMRA which reclassifies the he rules for resident into a therapy group may be combined with another assessment, per t combining assessments discussed in Sections 2.10 through 2.12 of this manual .  Example 1: Mr. T classified into the RUG group RUA on his 30- day assessment with an ARD set for Day 30 of his stay. On Day 37, the facility checked the rapy provided to Mr. T. and found that while he did receive the amount of the requisite number of therapy minutes to qualify for this RUG category, he only received therapy on 4 distinct calendar days, which would make it impossible for -High Rehabilitation RUG group. Moreover, due to the him to qualify for an Ultra lack of 5 distinct calendar days of therapy and a lack of restorative nursing ify for a therapy RUG group. The facility completes a services, Mr. T. did not qual COT OMRA for Mr. T, with an ARD set for Day 37, on which he qualifies for LB1. Mr. T’s rehabilitation regimen continues from that point, without any discontinuation of therapy or three consecutive days of missed therapy. On Day 44, the facility checks the amount of therapy provided to Mr. T during the previous 7 days and finds that Mr. T again qualifies for the RUG -IV therapy group RUA. In example 1 above , because Mr. T had qualified into a RUG -IV therapy group on a prior assessment during his current Medicare Part A stay (i.e., the 30 -day assessment) an d no discontinuation of therapy services (planned or unplanned) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her OT -IV group (Day 31, in this scenario) and the ARD of the C current non- therapy RUG -IV therapy group (Day 44, in this OMRA that reclassified the resident into a RUG scenario), the facility may complete a COT OMRA with an ARD of Day 44 to reclassify Mr. T. back into the RUG -IV therapy group RUA. day assessment  Example 2: Mr. A classified into the RUG group RVA on his 30- with an ARD set for Day 30 of his stay. On Day 37, the facility checked the amount of therapy provided to Mr. A during the previous 7 days and found that while he did receive the requisite number of therapy minutes to qua lify for this RUG category, he only received therapy on 4 distinct calendar days, which would make it impossible for him to qualify for a Very -High Rehabilitation RUG group. Moreover, due to lack of 5 distinct calendar days of therapy and a lack of restora -IV therapy group. tive nursing services, Mr. A did not qualify for any RUG The facility completes a COT OMRA for Mr. A, with an ARD set for Day 37, on which he qualifies for LB1. Mr. A’s rehabilitation regimen is intended to continue from that point, but M r. A does not receive therapy on Days 36, 37 and 38. On Day 44, the facility checks the amount of therapy provided to Mr. A during the 2-57 October 2018 Page

81 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH previous 7 days and finds that Mr. A again qualifies for the RUG -IV therapy group RVA. In example 2 above, while Mr. A ha -IV therapy group on a prior d qualified into a RUG assessment during his current Medicare Part A stay (i.e., the 30 -day assessment), a discontinuation of therapy services occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non- therapy RUG- IV group and the ARD of the COT OMRA that reclassified the resident into a RUG- IV therapy group (i.e., the discontinuation due to Mr. A missing therapy on Days 36- 38). Therefore, the facility may not compl ete a COT OMRA with an ARD of Day 44 to reclassify Mr. A back into the RUG -IV therapy group RVA. • A COT OMRA may be used to reclassify a resident into a RUG -IV therapy group only MRA -therapy by a previous COT O -IV non when the resident was classified into a RUG (which may have been combined with another assessment , per the rules for combining assessments discussed in Sections 2.10 through 2.12 of this manual ). — For example: Mr. E classified into the RUG group RUA on his 14- day assessment with an ARD set for Day 15 of his stay. No unscheduled assessments were required or completed between Mr. E’s 14- day assessment and his 30- day assessment. On Day 29, the facility checked the amount of therapy provided to Mr. E during the previous 7 days and found that while he did receive the requisite number of therapy minutes to qualify for this RUG category, he only received therapy on 4 distinct calendar days, which would make it impossible for him to qualify for an Ultra -High Rehabilitation RUG group. Moreover, due to lac k of 5 distinct calendar days of therapy and a lack of restorative nursing services, Mr. E did not qualify for any RUG -IV therapy group. The facility completes a 30 -day assessment for Mr. E, with an ARD set for Day 29, on which he qualifies for LB1, but opts not to combine this 30- day assessment with a COT OMRA (as permitted under the COT rules outline d in Section 2.9 of the MDS 3.0 manual) . Mr. E.’s rehabilitation regimen continues from that point, without any discontinuation of therapy or three consecutive days of missed therapy. On Day 36, the facility checks the amount of therapy provided to Mr. E during the previous 7 days and finds that Mr. E again qualifies for the RUG -IV therapy group RUA. IV therapy group on a , although Mr. E had qualified into a RUG- above In th e scenario prior assessment during his current Medicare Part A stay (e.g., the 14 -day assessment), the assessment which classified Mr. E into a RUG -IV non- therapy group was not a COT OMRA. Therefore, the facility may not complete a COT OMRA with an ARD of Day 36 to reclassify Mr. E back into the RUG -IV therapy group RUA. If a resident is classified into a non -therapy RUG on a COT OMRA and the facility subsequently decides to discontinue therapy services for that resident, an EOT OMRA is not required for this resident. • Wh en the m ost recent as sessm ent us ed f or PPS, e xc luding an E nd o f The rapy OMR A, ha s lify a su ffi cient l eve l of reha bili tation th erap y to qua igh, for a n Ultr a H igh, V ery High, H Medium Low Reha bil itation cat egor y (even if the f inal c lassification ind ex m aximiz es , or to a g roup be low Reha bilitat ion) , then a c ha nge in the pr ovi sion of therap y s ervices is y obs evaluated in s 7 -day Ch ange of Therap uccessive ervation per iods unt il a n ew ccur ed for PPS o ent us s. ssm asse 2-58 October 2018 Page

82 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • pleted ( Item Z0500B) within 14 da ys a fter t he ARD ( ARD + 14 days). Must be com Estab lishes a new RUG -IV categ ory. Pa yment begins on Day 1 of that COT observation • rrent payment period, unless the paym ent period and continues for the remainder of the cu is modified by a subsequent COT OMRA or other PPS assessm ent. within 14 bm itted ele ctronical ly and accep ted in to the QIES ASAP system • Must be su fter completion (It em Z0500 B) (co mpletion + 14 days). days a Significant Change in Status Assessment (SCSA) • Is an OBRA -requir ed as sess me nt. See Section 2 .6 of this ch apter for de finition, guidel ines i mpletion, and scheduling. n co blish a new R UG- IV clas sif ication. • May esta When a SC SA f or a SNF • nt is not co mbined with a PPS assess ment (A0310A PPS reside = 04 and A0310B = 99), t he RUG -IV clas sif ication and associ ated pay ment rate begin on the ARD. For exa mple, a SCSA is co mpleted with an ARD of day 20 then the RUG- IV clas sif ication begins on day 20. When the SCSA is com pleted w • led Medica re-required as sessm ent and grace ith a schedu days are n ot used when setting the ARD, the RUG- IV clas sif ication begins on the ARD. day s For exa mbined with the Me dicare-r equ ired 14- mple, the SCSA is co cheduled assessment and the ARD is set on day 13, the R UG -IV clas sif ication begins on day 13. ssessment and the quired a re-re led Medica • When the SCSA is com pleted w ith a schedu ARD is set within the g race days, -IV classi fication begins on the first day of the the RUG cheduled Me re-r equ ired ass essm ent s tandard pay ment period. payment period of the s dica mple, the SCSA is co mbined with the Me For exa equ ired 30- day s cheduled dicare-r assessment, which pays for days 31 to 60, and the ARD is set at day 33, t he RUG- IV classification begins day 31. Swing Bed Clinical Change As se ssment s. Sta uir ed assessm ent • Is a req ff is res ponsible f or d eter mining for swing bed provider whether a change ( eith er an i mprovement or decline) in a pa tient’s con dition consti tutes a “cli nic al ch ange” in t he patie nt’s st atus. Is si • milar to the OBRA S igni ficant Change in Sta tus Assessm ent with the ex cep tions of the CAA process and the tim ing rel the OBRA Admission asses sm ent. See ated to 2.6 of this chapter. Section May esta blish a new R UG- IV clas sif ication. See previous Signif • ange in Status icant Ch subsection f or ARD implic ations on the paym ent schedule. Significant Correction to Prior Comprehe nsive Ass essment .6 of • -requir ed as sess ment. See Section 2 Is an OBRA this ch apter f or defi nition, guidel ines i n co mpletion, and scheduling. • May esta blish a new R UG- IV clas sif ication. See previous Signif icant Ch ange in Status ations on the paym ent schedule. or ARD implic subsection f 2- 59 October 2018 Page

83 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Coding ations Tips and Special Popul When coding a standalone Change of Therapy OMRA (CO dal one End of T), a stan • tan Therapy OMRA (EO art of Therapy OMRA (SOT ), the inter vie w T), or a s dalone St ay be coded using the respo nses provided by the re sident on a pre vious items m assessm ent if the DATE of the inte rview responses from the previous assessm ent (as only em 400) were obtained no more than 14 days pri or to the DATE of documented in it Z0 ms on the unsched uled ass essment (as docum ented in completion for the interview ite item Z0400) for which those responses will be used. • When coding a standalone Change of Therapy OMRA (CO T), a stan dal one End of Therapy OMRA (EO T), or a s tan dalone St art of Therapy OMRA (SOT ), f acil ities must set t he ARD essment f or a day within the allowable ARD window for that for the ass ent type, but may only do so no m dow has passed. an two days af ter the win assessm ore th rd mple, if Day 7 of the COT observation pe riod is May 23 For exa and the COT is rd and this must be done by required, then the ARD for this COT m ust be set for May 23 th lexi . Fa ciliti es m ay sti ll ex ercise the use of t his f May 25 bil ity period in c ases where t he resident d harges f rom the f aci lity during that p eriod. isc • Note: In lim ited c ircu mstances, it may not be pra cti cable to conduct the r esident inte rview portions of the MDS (Sect ions C, D, F, J) on or prior to t he ARD f or a stand alone terv esident in e the r iews (and not the unscheduled PPS assess ment. In such cases wher staff assessm pleted and the ass essm ent is a standalone unscheduled are to be com ent) s m ay conduct the resi dent inter view po rtions of th at assessment up assessment, provider 300). lendar days ter the A RD (Item A2 af to two ca Combining Medicare Scheduled and Unscheduled 2.10 Assessments There m ay be ins tances when more than one Me dicare-r equ ired ass essm ent is d ue in the sam e time period. To reduce provider burden, CMS allo mbining of ass essments. Two ws the co Medica re-required Scheduled Assessm ents ents have ay never be combined sinc e these asse ssm m that a specif ic ARD win dows that do not occur at the sam e ti me. However, it is possi ble Medica re ay be ent m re-required Scheduled Assessm ent and a Medica Unscheduled Assessm combined or that two M e Uns cheduled as sessm ents ma y be co mbined. edicar When combining as sessments, the m ore st ringe nt req uire ments must be m et. For example, when a Sta rt of Therapy OMRA is co mbined with a 1 4-Day Medi care- requ ired Assessment, the PPS item set must be used. The PPS item ns a set contai ll the req uired ite ms for the 14- Day Medic are- required as eas the S tart of Therapy OMRA it em set con sists of f ewer items, thus sessment, wher the provider would need to com plete the PPS item set. The ARD window (including grace da ys) for the 14-day assessm ent is days 1 3-18, therefor e, the ARD m ust be set no lat er than day 18 to e f ed tim et. For a swing bed provider, the swing bed ensure th at a ll requir rames are m PPS item set would need to be com pleted. 2- 60 October 2018 Page

84 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH ment (OMRA, SCSA, SC PA, or If an unsche duled PPS assess DEFINITION in the assessment window Swing Bed CCA) is required USED FOR PAYMENT cluding grace da (in ed PPS assessm ent that has ys) of a schedul assessment is considered An litie s must combine the not yet be en perform ed, then f aci to be “used for payment” in et ting the ARD of ents by s essm and unscheduled ass scheduled that it either controls the at the unschedul ed ule d assessm ent for the sam e day th the sched payment for a given period acil n such cases, f ired. I s requ ent i ities assessm should provide or, with scheduled r response to the A0310 items to indicate which the prope assessments, may set the ombined, as completion of the eing c ents are b assessm basis for payment for a given requirements taken to fulf ment will be combined assess ill the period. essments. A and unscheduled ass for both the scheduled n the ass ter cur af PS assessment cannot oc scheduled P essm unscheduled assess an ment i ent mbined with the unscheduled assessment using must be co ent essm eduled ass ow—the sch wind this pol icy is to minim te A the appropria RD for the unscheduled assessment. The purpos e of ize e that the the number of assessm ents required f or SNF PPS pa yment purposes and to ensur al cl inic ate pict ost accur as sessments used for payment provide the m ure of the resident’s condition and service nee ds. More det ails about combining PPS asse ssments are provided in this al (CMS Pub. laims Processing Manu re C r 6, Section 30.3 of the Medica chapter and in Chapte elow are so me of the poss ible assess ment 100-04) available on the CMS web site. Li sted b two assessm combinations allowed. A provider may choose to co mbine mo re than ent types when Item A0310 will into the soft ding of all requ irements ar e m et. When entered dire ctly ware the co pr aci co ired to is requ lity at to the f set that tem ovide the i er form mplete. For SNFs that use a pap ct MDS data, t he pro vider must ensure tha t the item set se lected m eets the requirements of colle A0310 (see Section 2.15). em sments coded in It all asses to co ity f acil a f mbine a sched heduled PPS assess ment as requ ired uled and unsc ails In cases wh en olled by the uns ntr ent is co cheduled ass ment. For essment policy, the paym mbined ass by the co ess MRA is set for Day 14 and the ARD of a 14- day as sess ment is exam ple: if the ARD of an EOT O MRA the EOT O equently, ment policy. Cons mbined assess ate the co set for Day 15, this would viol nto would control the payment. The EOT would begin payment on Day 12, and continue paying i day pay ment wi heduled as sessment used for paym ent. the 14- ndow until the next scheduled or unsc PPS Sche duled As sessment and Start of Therapy OM RA t within the ARD window for req A2300) must be se uired • the Medicare- ARD (Item tem tart of therapy (I 5–7 days after the s and ent sessm as scheduled O0400A5 or both ARD requirem ents are not O0400B5 or O0400C5, whichever is the ear liest dat e). If met, the assess ments may not be co mbined. • ces s dow ili tation servi ithin the ARD win An SOT OMRA is not necess ary if rehab tart w (in cluding grace da ys) of the 5 -day a ssessm ent, since t he ther apy ra te will be paid s tart ing Day 1 of the SNF stay. grace da • ys) of a If the ARD for the SOT OMRA f alls within the ARD window (including PPS scheduled assess at has not been perform ed yet, the assess ments MUST be ment th combined. s et. he PPS item plete t Com • Code the I ollows: • tem A0310 of the MDS 3.0 as f 2- 61 Page October 2018

85 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH A0310A = 99 A0310B = 01, 02, 03, 04, or 05 as appropr iate A0310C = 1 A0310D = 0 (Swing Beds only) and End of MRA duled As Therapy O sessment PPS Sche A2300) must be se • the window for the Medica re sch eduled ARD (Item t within assessm 1–3 days af ter t he l ast day t herap y was furnished (It em O0400A6 or ent and whichever is the l atest d ate). If both ARD require ments are not O0400B6 or O0400C6, ments m ay not be c met, the assess ombined. • If the ARD for the EOT OMRA f alls within the ARD window (inclu ding grace da ys) of a ment th ed yet, the assess ments MUST be PPS scheduled assess at has not been perform combined. Must co mplete t he PPS item set. • tem A0310 of the MDS 3.0 as f • ollows: Code the I A0310A = 99 A0 310B = 01, 02, 03, 04, or 05 as appropriate A0310C = 2 A0310D = 0 (Swing Beds only) PPS Sche sessment and Start a nd End of Therapy O MRA duled As led uired schedu re-req • w for the Medica ARD (Item A2300) must be se t within the windo th assessm ter t he s tart of 5–7 days af erapy (Item O0 400A5 or O0400B5 or and ent hichev er is e arlies t) and 1–3 days a was furnished st d ay therapy O0400C5, w fter the la (Item 00A6 or O0400B6 or O0400C6, whichever is late st). If al l thr ee ARD O04 requirements are not m ssessm ents m ay not be co mbined. et, the a • If the ARD for the EOT and SOT O MRA f alls within the ARD window (in cluding g race days) of a PPS schedul ed assessm ent th at has n ot been p erform ed yet, the assess ments MUST be combined. Mu • st co mplete t he PPS item set. • Code the I tem A0310 of the MDS 3.0 as f ollows: A0310A = 99 310B = 01, 02, 03, 04, or 05 as appropriate A0 A0310C = 3 A0310D = 0 (Swing Beds only) PPS Scheduled Assessment and Change of Therapy OMRA • The ARD must be set within the window for the scheduled assessment and on day 7 of the COT observation period. If both ARD requirements are not met, the assessments may not be combined. ment i set. tem • Must co mplete t he sch eduled PPS assess 2- 62 October 2018 Page

86 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • sessm ent is co mbined with the COT OMRA, the combined Since the scheduled as et paym assessm ginning on Day 1 of the COT ent at the new RUG ent will s -I V level be ue through the rem of the current ntin ainder observation period and that paym ent will co ven schedul ed standard payment period and the next payment period appropr iate to the gi intervening assessments. For exam ple: ming no ent, assu assessm Based on her 14- — ssessment, Mrs. T is curre ntly c las sified into group RVB. day a -da ent, a change of therapy evaluation f or Based on the ARD set for the 14 y assessm Day 28. The change of ls th aluation revea ecessary on at the Mrs. T is n therapy ev rs. T r eceived d uring that COT observation period were only therapy s ervices M qualif y Mrs. T f or R sufficient to fore, a COT OMR A is requ ire d. Since the HB. There facil not yet co mpleted a 30 -day assessm ent f or Mrs. T, the f aci lity must ity has day ass ent with the req uired COT OMR A. The combined combine the 30- essm ent con firms Mrs. T’s appropri ate cl assi fica tion into RHB. The pay ment f or assessm RUG classi suming no intervening the revised fication will begin on Day 22 and, as ents, will co ntinue until Day 60. assessm tem A0310 of the MDS 3.0 as f ollows: • Code the I A0310A = 99 310B = 01, 02, 03, 04, or 05 as appropriate A0 A0310C = 4 A0310D = 0 (Swing Beds only) PPS Sche duled As sessment and Swing Bed Clinical Change Asses sm ent led uired schedu re-req • w for the Medica ARD (Item A2300) must be se t within the windo assessm ent within 14 days afte r the inte rdi scip linary te am (IDT) de termination t hat a and change change in ’s condition co nstit utes a clinical ient and the as sess ment must be the pat completed ( Item Z0500B) within 14 days a fter the IDT determ ines that a change in the patie condition con stit utes a cli nical change. If all requi rements are not m et, the nt’s assessm ents may not be combined. • If the ARD for the Swing Bed Clinic al Change Assess ment f alls within the ARD cluding grace da (in et, ys) of a PPS scheduled ass essment that has not been com pleted y the ass essm mbined. ents MUST be co mplete t he Swing Bed PPS item set. • Must co Code the I tem A0310 of the MDS 3.0 as f • ollows: A0310A = 99 (only valu e allowed fo r Swing Beds) A0310B = 01, 02, 03, 04, or 05 as appropr iate A0310C = 0 A0310D = 1 Swing Bed Clinical Change As sessment and Start of Therapy OM RA • ARD (Item A2300) must be se t within 14 days af ter the IDT deter mination that a change in the pa tient’s con dition constitutes a cli nic al change and 5–7 days af ter the s tart of therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is ear liest) and the ter the Z0500B) within 14 days af mination IDT deter assessm ent m ust be co mpleted (I tem 2- 63 October 2018 Page

87 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: ments ient’s con dition consti tutes a clinic al change. If al l req uire ge in the pat that a chan et, the ass essm ents may not be combined. are not m Must co • he Swing Bed PPS item set. mplete t • Code the I tem A0310 of the MDS 3.0 as f ollows: A0310A = 99 A0310B = 07 A0310C = 1 A0310D = 1 Swing Bed Clinical Change As sessment and End of Therapy O MRA • ARD (Item A2300) must be se t within 14 days af ter the IDT deter mination that a change the l in the pa nic al change and 1–3 days a fter dition constitutes a cli ast day tient’s con therapy was furnished ( Item O0400A6 or O0400B6 or O0400C6, whichever is the lat est) and the ass essm ent m ust be co mpleted (Item Z0500B) within 14 days afte r the IDT al l deter ien t’s condition const itut es a clinic al change. If mination that a change in the pat requirements are not m et, the a ssessm ents m ay not be co mbined. mplete t set. he Swing Bed PPS item • Must co • tem A0310 of the MDS 3.0 as f ollows: Code the I A0310A = 99 A0310B = 07 A0310C = 2 A0310D = 1 sessment and Start a nd End of Therapy O MRA Swing Bed Clinical Change As ARD (Item t within 14 days A2300) must be se • after the IDT deter mination that a chan ge in the pa tient’s con dition constitutes a cli nic al change and 5–7 days af ter the s tart of 1–3 therapy (Item O0400A5 or O0400B5 or O0400C5, whichever is the earl ies t) and e las herapy was tem O0400A6 or O0400B6 or O0400C6, days a fter th furnished (I t day t atest) and the assessm ent must be co mpleted (Item Z0500B) within 14 is the l whichever days a fter th e IDT determ ination th at a change in the pat ien t’s condition constitutes a cli nical chan ge. If all re quire ments are not m et, the assess ments may not be combined. • Mu st co mplete t he Swing Bed PPS item set. Code the I tem A0310 of the MDS 3.0 as f ollows: • A0310A = 99 A0310B = 07 A0310C = 3 A0310D = 1 2- 64 October 2018 Page

88 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH 2.11 Combining Medicare Assessments and OBRA 7 Assessments eet t SNF providers a tandar ds in a Me di care ce rtified nursing ent s uired to m wo assessm re req ity: facil • ds a re design ated by the r eason selec ted in Item A0310 A, Federal The OB RA standar sessment , a nd Item A01 30F, Entry/Discharge R OBRA Re and are ason for As eporting red f resi dents. requi or all The Medica A0310B, dards are des igna ted by the re ason sel ected in I tem PPS • re stan sment - , Item PPS Other M edicare Requ ired Asses A 0310C, OMRA , an d Assessmen t Is t his a SNF Part A PPS Discharge Assessment ?, and are req uired f or Item A0310H, s who se stay is co vered by Medicar e Part A. resident When the OBRA and M are as sessm ent tim e f rames coi ncide, one a ssess ment may be • edic y both require ents m RA assessm atisf ay be c om bined when the used to s ments. PPS and OB ndows over f or a co mmon assess ment ref ere nce date. When ARD wi lap allowing and Medic are assessm ents, the m ost stringe nt req uire ments f or ARD, combining the OBRA ite m set, and CAA co mpletion requi ust be m et. For exam ple, the ski lled nursing rements m or an OB taff m eful in se lect ing the ARD f car RA A dm ission facility s us t be very ent co mbined with a 1 4- day assessm re as sessm ent. For the OBRA A dm ission Medica standard, the ARD m ust be set b etween days 1 a nd 14 counti ng the da te of admission as tion a gula re f or days 13 or 14, but the he ARD day 1. For Medic are, t llows m ust be set grace da ys up to day 18. bining a 14 -da y Medic are assess ment with However, when c om mission assessm se of grace days f or the PPS assess ment would resu lt in a the Ad ent, the u dm ission assessm ent. To assure t he assessm ent m eets both standar ds, a n ARD late OBRA A 13 or 14 would have to be chosen in this s itu ation. In addi tion, the com pletion of day hile a PPS assess ds m ust be m et. W fter ment can be co mpleted w ithin 14 days a standar t he ARD wh ot c om bined with an OBRA assessm ent, the CAA co mpletion date f or the en it is n OB RA A dmission a ssess ment (Item V0200B2) m ust be day 14 or ear lier. With the combined OBRA Ad mission/ Medica re 14 -day assess ment, co mplet ion by day 14 would be ent, the req uired. Fi nall y, when c om bining a Me dicar e ass essment with an OB RA assessm ff m re th mbining hen co mple, w ust ensu pleted. For exa at all req uired ite ms are c om SNF sta the Medi requ ired 30- day ass care- ent with a Signif icant Change in Status Ass essment, essm the provider woul d need to c om plete a com prehensive item set, includi ng CAAs. addi Som requi re pro viders to co mplete e states tional s tate-specific i tems (Section S) f or sel ected assessm om ents. States m ay also add c prehensive ite ms to the Quarter ly a nd/or PPS i tem sets. Providers m e that they f ol low their s tate requi rements in addi tion to any OB RA and/or ust ensur Medica re re quire ments. 7 OBRA -requ ired comprehensive and Quarterly assess ments do not appl y to S wing Bed P roviders. However, h in Fac y ilit Sw ing Bed P roviders are r equi red to complete the Entry R ecord, Discharge Asse ssments, and Deat ord. Rec 2-65 October 2018 Page

89 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI a ssessm rovide the ite m set f or e ach type of es p ent or trac king r ecord. W hen The f ollowing tabl ore assessm ents are co mbined then t two or m ppropri ate i tem set contains al l i tems that would he a be necessary the com bined ass essm ents were being co mpleted if e ach of individually. Minimum Required Item Set By Assessment Type for Skilled Nursing Facilities Comprehensive Other Required Assessments Quarterly and PPS* Item Set and Tracking Records/ Item Sets Item Sets Stand -alone Entry Tracking Record • OBRA Admission Quarterly • • Assessment • Annual • • Significant Correction to Prior Discharge assessments OBRA Types Quarterly • Death in Facility Tracking Significant Change in • Record Status (SCSA) -Day) -Day (5 PPS 5 • PPS 14 -Day (14 -Day) • Discharge PPS • Significant Correction to Part A • Prior Comprehensive • -Day) -Day (30 PPS 30 • herapy OMRA Start of T (SCPA) -Day) PPS 60 • Change of Therapy OMRA • -Day (60 End of Therapy PPS 90 -Day) -Day (90 • OMRA • Combined • OBRA Admission and 5 - Quarterly and any Medicare- • of Therapy OMRA and Start • Day scheduled of Therapy OMRA End Assessment Types OBRA Admission and 14- • • Quarterly and any OMRA Start of Therapy OMRA and • Day OBRA Discharge required • Medicare and any • OBRA Admission and any OMRA • End of Therapy OMRA and OMRA OBRA Discharge Significant Correction to Prior • • - Annual and any Medicare Quarterly and any Medicare- • Start of Therapy OMRA and PPS required required End of Therapy OMRA and OBRA Discharge • Annual and any OMRA Significant Correction to Prior • Quarterly and any OMRA Change of Therapy OMRA • • SCSA and any Medicare- and OBRA Discharge required Medicare and required any • Any Discharge • SCSA and any OMRA Quarterly and OMRA Discharge • SCPA and any Medicare- • required Significant Correction to Prior • Quarterly and any Discharge • SCPA and any OMRA Any OBRA • comprehensive and any Discharge *Provider must check with State Agency to determine if the state requires additional items to be completed for the required OBRA Quarterly and PPS assessments. 2-66 Page October 2018

90 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI Minimum Required Item Set By Assessment Type for Swing Bed Providers Other Required Assessments/Tracking Item Sets for Swing Bed Providers Swing Bed PPS /Item Set PPS 5 -Day (5 -Day) Assessment Type Entry Record • • Discharge assessment OBRA • • PPS 14 -Day (14 -Day) PPS 30 -Day) -Day (30 • • Death in Facility record • -Day) -Day (60 PPS 60 • Start of Therapy OMRA Change of Therapy OMRA • • PPS 90 -Day (90 -Day) • End of Therapy OMRA Swing Bed Clinical Change Assessment • • Assessment Type Any Medicare required and any OMRA of of Therapy OMRA and End Start • * Combinations Therapy OMRA • any Discharge and Any Medicare required Start of Therapy OMRA and OBRA • Swing Bed Clinical Change and any • Discharge Medicare required • End of Therapy OMRA and OBRA Swing Bed Clinical Change and any • Discharge Discharge • Start of Therapy OMRA and End of Therapy OMRA and OBRA Discharge • Change of Therapy OMRA and OBRA Discharge Tracking records (Entry and Death in Facility) are never combined with other assessments. The OMRA item sets are all u nique it em sets and are nev er c ompleted when combining with other as ses sments, which requir e completion of additional items. For exam ple, a Start of sment is conducted to cap mpleted only when an asses co ture the Therapy OMRA item s et is sta rt of ther and assi gn a RUG -IV therapy group. In addition, a Start of Therapy OMRA apy aci it set is only co mpleted when the f and OBRA Discharge lity s taff choose t o co mplete an em assessm ent t o re flect both the sta rt of ther apy and discharge f rom fa cility . If asse ssme nts are item completed in co essm ent type, an her ass set that contai ns a ll items mbination with anot requir ed for both asse ssm ents must be sel ected . 2.12 Medicare and OBRA Assessment Combinations Below are som e of the allowed possible asse ssm ent combinations. A provider may choose to ent types when all requireme combine mo re than two assessm nts are m Item et. The coding of ired to A0310 will provide the i aci lity is requ the f co mplete. For SNFs that use a set that tem t to c olle ct MDS data, the provider must ensure that the i tem set s elected m eets the paper forma sments coded in It em A0310 (see Section 2.15). requirements of all asses dicare- ission As required 5- Day and OBRA Adm Me sessment • Comprehensive i tem set. • ARD (Item A2300) must be set on days 1 through 5 of the Part A SNF stay. • ARD m ay be extended up to day 8 using the de signated g race days. te plus Item Z0500B) by the end of day 14 of the stay ( pleted ( ust be com admission da M • ar days). 13 calend 2- 67 October 2018 Page

91 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan See Section completion. dicare- -Day and OBRA Ad mission Assessment required 14 Me tem set. • Comprehensive i ARD (Item • the Part A SNF stay. A2300) must be set on days 13 or 14 of • ARD m ay not be ex tended from day 15 to day 18 (i.e., gr ace days m ay n ot be used). • Must be com pleted ( Item Z0500B) by the end of day 14 of t he stay ( admission da te plus 13 calend ar days). • 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan See Section completion. sment required S Me Assessment and OBRA Quarter ly Asses dicare- cheduled • Quarter ly item set as required by the State. • ARD (Item A2300) must be set on a day that m eets the requ irem ents described e arlier for each dic are-r equ ired scheduled ass ess ment in Section 2.9 and for the OBRA Quart erly Me assessm ent in Section 2.6. • ARD m ay be extended to grace da ys as long as the requi rement for the Quarte rly ARD is met. s. ent mpletion requirem • See Section 2.6 f or OB RA Quarterly assess ment co Me dicare- cheduled Assessment and Annual Asses sment required S set. tem • Comprehensive i • A2300) must be set on a day that m eets the requ irem ents described e arlier for ARD (Item each Medic are-r equ ired scheduled ass ess ment in Section 2.9 and for the OBRA Annual assessm ent in Section 2.6. • AR D m ay be extended to grace da ys as long as the requi rement for the A nnual ARD is met. RA Annual assess See Section 2.6 f or OB • ment co mpletion require ments. • 2.7 and Chapter 4 f See Section or requ irements for CAA process and car e p lan completion. Me required S cheduled Assessment and Signi ficant Change in Sta tus dicare- sm ent Asses • Comprehensive i tem set. • ARD (Item A2300) must be se t within the windo w for the Medica re-req uired schedu led assessment and within 14 days a deter mination that cri teria are m et for a Signif icant fter Change in Status asses sm ent. • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he deter mination that the cri teria ent. sm Change in Status asses are m et for a Signif icant 2- 68 October 2018 Page

92 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan See Section completion. rection to P cheduled Me and Signi ficant Cor required S rior dicare- Assessment nsive Ass essment Comprehe Comprehensive i tem • set. • ARD (Item A2300) must be se t within the windo w for the Medica re-req uired schedu led ficant ent within 14 days afte assessm eter mination that an uncorre cted signi and r the d error in the prior co mprehensive as sess ment has occur red. • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he deter mination that an uncorre cted ficant e rror in the pr ior co mprehensive as sessment has occurr ed. signi See Section 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan • completion. Me dicare- required S cheduled Assessment and Signi ficant Cor rection to P rior Quarterly ssm ent Asse • See Medi care- req uired Scheduled As sessm ent and OB RA Quart erly Ass essm ent. Me dicare- required S cheduled Assessment and OBRA Discharge Ass essment set. PPS item • • t f or the day of discharge (Item A2000) and the date of ARD (Item A2300) must be se all w e schedu led assessm ent as ge must f dischar ithin the allowed window of the Medicar rlier in S ection 2.9. descri bed ea • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD. Assessment required S cheduled Me and Part A PPS Discharge dicare- As sessment • PPS i tem set . ARD (Item • t f or t he last day of the Medicare Part A Stay (A2400C) A2300) must be se and the last day of the Medicare Part A stay must fall w ithin the a llowed window of the Me dicar e schedu led assessm ent as descri bed ea rlier in S ection 2.9. • pleted ( Item Z0500B) within 14 da fter t he ARD. Must be com ys a of Th OM RA and OBRA Adm ission As sessment Start erapy Comprehensive i tem • set. • ARD (Item A2300) must be set on day 14 or earl ier of the stay and 5–7 da ys a fter t he start of therapy (I tem O040 0A5 or O0400B5 or O0400C5, whichever is the e arliest dat e). lita tion • Com pleted t o clas sif y a resident into a RUG -IV Rehabi Plus Exten sive Ser vices or Rehabil itation group. If the RUG -IV clas sif ication is not a th erapy group, the ass essm ent are bi lling. CMS and cannot be used for Medic will not be a ccepted by 2- 69 October 2018 Page

93 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • pleted ( Item Z0500B) by day 14 of the s tay (a dmission date plus 13 calendar Must be com days). e p 2.7 and Chapter 4 f or requ irements for CAA process and car lan • See Section . completion of Th erapy OM RA and OBRA Quarterly Asse ssment Start Quarter ly item set as required by the State. • the start of th t 5 –7 days a fter A2300) must be se erapy ( Item O0400A5 or • ARD (Item whichever O0400B5 or O0400C5, rliest date) and m eet t he req uirements for an is the ea OB RA Quarte rly assessm ent as described in Section 2.6. or • Com pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices Rehabil itation group. If the RUG erapy group, the ass essm ent -IV clas sif ication is not a th ccepted by for Medic are bi lling. will not be a CMS and cannot be used See Section 2.6 f or OB RA Quarterly assess ment co mpletion requirem ent s. • Start of Th erapy OM RA and An nual Ass essment • Comprehensive i tem set . • O0400A5 or A2300) must be se t 5 –7 days a fter the start of th erapy ( Item ARD (Item ent as O0400B5 or O0400C5) and m eet the requ irements for an OBRA Annual asse ssm bed in descri Section 2.6. or • pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices Com itation group. If the RUG sif ication is not a th erapy group, the ass essm ent -IV clas Rehabil ccepted by CMS and cannot be used for Medic are bi lling. will not be a • S 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan ee Section completion. Start of Th erapy OM RA and Significant Change in Status Assessment • Comprehensive i tem set. re • ARD (Item A2300) must be se t within 14 days after the d eterm ination th at crite ria a ent apy 5–7 days af met f or a S igni ficant C hange in St atus assessm rt of ther and the sta ter (Item 00A5 or O0400B5 or O0400C5, whichever is the ear liest dat e). O04 • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD and within 14 days af ter et for a Signif the det that the cr iteria a re m ermination icant C hange in Stat us assessm ent. Com • pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices or Rehabil -IV clas sif ication is not a th erapy group, the ass essm ent itation group. If the RUG will not be a ccepted by CMS and cannot be used for Medic are bi lling. • and Chapter 4 irements for CAA process and car e p See Section 2.7 lan for requ completion. 2- 70 October 2018 Page

94 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Start OM RA and Significant Correction to Prior Comprehe nsive of Th erapy ent sm Asses Comprehensive i tem set. • A2300) must be se t within 14 days after det erm ination that an uncorre cted • ARD (Item ficant e rror in a comprehensive assessm ent has occu rred signi and 5–7 days af ter t he s tart of therapy (I O0400A5 or O0400B5 or O0400C5, whichever is the e arliest dat e). tem he ARD and within 14 days af pleted ( Item Z0500B) within 14 da ys a fter t • ter Must be com the det that an uncorre cted signi ficant error in a comprehensive assessm ent has ermination occur red. • pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices or Com itation group. If the RUG Rehabil sif ication is not a th erapy group, the ass essm ent -IV clas will be a ccepted by CMS and cannot be used for Medic are bi lling. not • See Section 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan completion. of Th erapy OM RA and Significant Correction to Prior Quarterly Assessment Start • See SOT O MRA and O BRA Quart erly Assessm ent . Start of Th erapy OM RA and OBRA Di scharge Assessment set. ge item and Dischar • Start of The rapy OMRA • A2300) must be se t f or the day of discharge (Item A2000) and the date of ARD (Item ge must f ithin 5–7 days af ter the s tart of therapy (I tem O0400A5 or O0400B5 dischar all w ear liest dat e). The ARD must be set by no more than t wo or O0400C5, whichever is the or f fter dis charge. (See Section 2.8 f the date of urther c lari fication .) days a • Co -IV o clas sif y a resident into a RUG pleted t Rehabi lita tion Plus Exten sive Ser vices or m Rehabil itation group. If the RUG -IV clas sif ication is not a th erapy group, the ass essm ent will not be a ccepted by CMS and cannot be used for Medic are bi lling. pleted ( • Must be com ys af Item Z0500B) within 14 da ter t he ARD. End of Therapy RA and OBRA Adm ission As sessment OM tem set. • Comprehensive i ARD (Item • ier of the sta y and 1–3 days af ter the last A2300) must be set on day 14 or earl day the rapy was furnished (di fferen ce is 3 or less for Item A2300 m inus I tem O0400A6 or O0400B6 or O0400C6, whicheve r is t atest). he l Must be com • Item Z0500B) by day 14 of the s tay (a dmission date plus 13 calendar pleted ( days). • Completed only when t he resi dent was clas sified in a RUG- IV Rehabil itation Plus Extensive S ervi ces or Rehabil ita tion group and continues to need Part A SNF -level ces afte tinuation of all therapies. r the discon servi 2- 71 October 2018 Page

95 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem Estab the l ast day of therapy tr ment. Z0150A), which begins the day af ter eat and Chapter 4 • lan e p 2.7 See Section irements for CAA process and car for requ completion. OM RA and OBRA Quarterly Asse ssment End of Therapy Quarter • ly item set as required by the State. ARD (Item y was s a fter t he l ast day t herap furnished (It em A2300) must be 1–3 day • atest) a nd m eet the requirem ents the l O0400A6 or O0400B6 or O0400C6, whichever is A Quarterly assessm ent as descr ibed in Section 2.6. for an OBR • he resi dent was clas sified in a RUG- IV Rehabil itation Plus Completed only when t ervi ces or R lita tion group and continues to need Part A SNF -level Extensive S ehabi r the discon ces afte tinuation of all therapies. servi Estab lishes a new non-t • sif ication and Medic are pay ment rate (I tem herapy RUG clas ter the l ast day of therapy tr Z0150A), which begins the day af ment. eat • See Section 2.6 f or OB RA Quarterly assess ment co mpletion requirem ent s. Therapy OM RA and A nnual Ass essment End of Comprehensive i tem set. • herapy was t day t • tem furnished (I ARD (Item A2300) must be se t 1–3 days a fter the las O0400A6 or O0400B6 or O0400C6, whichever is the l a nd m eet the requirem ents atest) A Annual assess bed in Section 2.6. for an OBR ment as descri Co • he resi dent was clas sified in a RUG- IV Rehabil itation Plus mpleted only when t Extensive S ervi ces or R ehabi lita tion group and continues to need Part A SNF -level servi r the discon tinuation of all therapies. ces afte • Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem Z0150A), which begins the day af ter the l ast day of therapy tr eat ment. 2.6 f • See Section ments. or OB RA Annual assess ment co mpletion require • 2.7 and Chapter 4 f or requ irements for CAA process and car e p lan See Section completion. End of OM RA and Significant Change in Status Assessment Therapy • Comprehensive i tem set. • ARD (Item A2300) must be se t within 14 days after the d eterm ination th at the cri teria are and met f ficant C hange in St atus assessm ent igni 1–3 days a fter the end of ther apy or a S (O0400A6 or O0400B6 or O0400C6, whichever is the la test date). • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD and within 14 days af ter hange in Stat ent. us assessm the det ermination that the cr iteria a re m et for a Signif icant C 2- 72 October 2018 Page

96 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • he resi dent was clas sified in a RUG- IV Rehabil itation Plus Completed only when t ces or R ehabi group and continues to need Part A SNF -level Extensive S lita tion ervi tinuation of all therapies. r the discon servi ces afte Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem • ter the l eat ment. Z0150A), which begins the day af ast day of therapy tr See Section lan or requ irements for CAA process and car e p • 2.7 and Chapter 4 f completion. Therapy End of RA and Significant Correction to Prior Comprehe nsive OM Asses sm ent Comprehensive i tem set. • ARD (Item A2300) must be se t within 14 days af ter the de term ination th at an uncorre cted • ficant e rror in the pr mprehensive as sessm ent has occur red and 1–3 days a fter ior co signi O0400A6 or O0400B6 or O0400C6, whichever is the l atest Item the end of therapy ( date). Must be com pleted ( Item Z0500B) within 14 da ys af ter t he ARD and within 14 days af ter • ermination uncorre the det cted signi ficant error in prior co mprehensive as sess ment that an rred. has occu Completed only when t he resi dent was clas sified in a RUG- IV Rehabil itation Plus • ervi ces or R ehabi lita tion group and continues to need Part A SNF -level Extensive S servi tinuation of all therapies. r the discon ces afte • lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem Estab ter eat ast day of therapy tr Z0150A), which begins the day af ment. the l • S ee Section 2.7 and Chapter 4 f irements for CAA process and car e p lan or requ completion. End of Therapy OM RA and Significant Correction to Prior Quarterly Assessment • MRA and OBRA Quart erly Assessm ent. See EOT O End of Therapy OM RA and OBRA Di scharge Assessment • OMRA and OBRA Discharge it em set. • ARD (Item A2300) must be se t f or the day of discharge (Item A2000) and the date of all w dischar ge must f last ithin 1–3 days af ter the day the rapy was furnishe d (Item O0400A6 or O0400B6 or O0400C6, whichever is the l must be se t by no atest). The ARD tion.) ter the d dischar ge. ( See Section 2.8 f or f more than two days af lari fica ate of urther c • Completed only when t he resi dent was clas sified in a RUG- IV Rehabil itation Plus Extensive S ervi ces or R ehabi lita tion group and continues to need Part A SNF -level servi r the discon tinuation of all therapies. ces afte • Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem Z0150A), which begins the day af ter the l ast day of therapy tr eat ment. ys a fter t he ARD. • Must be com pleted ( Item Z0500B) within 14 da 2- 73 October 2018 Page

97 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Start Therapy OM RA and OBRA Adm ission As sessment and End of Comprehensive i set. • tem and ARD (Item the sta y A2300) must be set on day 14 or earl 5–7 days af ter the • ier of rt of ther apy (Item O0400A5 or O0400B5 or O0400C5, w hichev er is e arlies t) and sta 1–3 days a the las t day t herapy was furnished (I tem O0400A6 or O0400B6 or O0400C6, fter is the l whichever atest). • Must be com pleted ( Item Z0500B) by day 14 of the s tay (a dmission date plus 13 calendar days). -IV • o clas sif y a resident into a RUG Com Rehabi lita tion Plus Exten sive Ser vices or pleted t Rehabil itation group ( Item Z0100A ) and into a non-ther apy group (I tem Z0150A) w hen the resident continue s to A SNF -level s ervi ces af ter the discontinuation of al l need Part If the RUG Z0100) is not a t sif ication (Item therapies. herapy gro up, the -IV clas ent will assessm be a ccepted by CMS and cannot be used for Medic are bi lling. not • Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem Z0150A), which begins the day af the l ast day of therapy tr eat ment. ter • and Chapter 4 2.7 lan for requ irements for CAA process and car e p See Section completion. Start and End of Therapy OM RA and OBRA Quarterly Asse ssment • Quarter ly item set. erapy (Item tart of th 400A5 or O0 • ARD (Item A2300) must be 5–7 day s a fter t he s last O0400B5 or O0400C5, an d 1–3 days af ter the liest) day the rapy was is ear whichever Item O0400A6 or O0400B6 or O0400C6, whichever is the lat est) and me et furnished ( uire ly assessm ent as des cribed in Section 2.6. ments for OBRA Quarter the req Com p • sif leted t o clas a RUG y a resident into -IV Rehabi lita tion Plus Exten sive Ser vices or hen Rehabil Item Z0100A ) and into a non-ther apy group (I tem Z0150A) w itation group ( the resident continue s to need Part A SNF -level s ervi ces af ter the discontinuation of al l roup, the therapies. If the RUG -IV clas sif ication (Item Z0100A) is not a ther apy g are bi lling. assessm ent will not be a ccepted by CMS and cannot be used for Medic sif ication and Medic • lishes a new non-t herapy RUG clas Estab are pay ment rate (I tem Z0150A), which begins the day af ter the l ast day of therapy tr eat ment. assess • See Section 2.6 f or OB RA Quarterly ment co mpletion requirem ent s. Ass Start and End of Therapy OM RA and An nual essment • tem set. Comprehensive i fter • t 5 –7 days a ARD (Item the start of th erapy ( Item O0400A5 or A2300) must be se O0400B5 or O0400C5, whichever is the ea rliest) and 1–3 days a fter t he l ast day ther apy was furnishe d (Item O0 400A6 or O0400B6 or O0400C6, whichev er is the lat est) and in essment requirem ents as described meet the require ments f or OBRA Annual ass Section 2.6. 2- 74 October 2018 Page

98 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices or Com tem Item and into a non-ther apy group (I ) Z0150A) w hen itation group ( Rehabil Z0100A need Part A SNF -level s ervi ces af ter the discontinuation of al l the resident continue s to -IV clas Z0100A) is not a ther apy g roup, the If the RUG therapies. sif ication (Item not be a ccepted by CMS and cannot be used for Medic are bi lling. assessm ent will Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem • the l ast day of therapy tr eat ment. ter Z0150A), which begins the day af See Section 2.6 f or OB • ment co mpletion require ments. RA Annual assess • and Chapter 4 2.7 for requ e p lan See Section irements for CAA process and car completion. Start Therapy OM RA and Significant Change in Status Assessment and End of Comprehensive i tem set. • ARD (A23 00) m ust be set within 14 days a fter the det erm ination th at the cr iteria are m et • for a Signi ficant Change as sessm ent and 5–7 days af ter the s tart of therapy in Status O04 fter ies t) and 1–3 days a (Item the 00A5 or O0400B5 or O0400C5, whichever is earl apy (O0400A6 or O0400B6 or O0400C6, whichever is the lat ate). end of ther est d Must be com • 0500B) within 14 days af ter the ARD and within 14 days afte r the pleted (Z Status a deter ent. ssessm mination that cri teria are m et for a Signif icant Change in • Co m pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices or apy itation group ( Z0100A ) and into a non-ther Item group (I tem Z0150A) w hen Rehabil SNF s to need Part A ces af -level s ervi the resident continue ter the discontinuation of al l therapies. -IV clas sif ication (Item Z0100A) is not a ther apy g roup, the If the RUG assessm ent will not be a ccepted by CMS and cannot be used for Medic are bi lling. herapy RUG clas • Estab lishes a new non-t sif ication and Medic are pay ment rate (I tem Z0150A), which begins the day af ter the l ast day of therapy tr eat ment. See Section • lan e p 2.7 and Chapter 4 f or requ irements for CAA process and car completion. Start End of Therapy OM RA and Significant Correction to Prior and Comprehe nsive As sessment • Comprehensive i tem set. • ARD (Item A2300) must be se t within 14 days after the d etermination th at an uncorre cted rror in the pr signi ficant e red ior co mprehensive as sessm ent has occur and 5–7 days a fter the s therapy ( Item O0400A5 or O0400B5 or O0400C5, whichever is ear liest) and tart of 1–3 days a fter the end of therapy (Item O0400A6 or O0400B6 or O0400C6, whichever is the l atest dat e). • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD and within 14 days af ter sess ment the det ermination that an uncorre cted signi ficant error in prior co mprehensive as has occu rred. 2- 75 October 2018 Page

99 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH • pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Plus Exten sive Ser vices or Com tem Item and into a non-ther apy group (I ) Z0150A) w hen itation group ( Rehabil Z0100A need Part A SNF -level s ervi ces af ter the discontinuation of al l the resident continue s to IV clas Z0100A) is not a ther apy g roup, the If the RUG- therapies. sif ication (Item not be a ccepted by CMS and cannot be used for Medic are bi lling. assessm ent will Estab lishes a new non-t herapy RUG clas sif ication and Medic are pay ment rate (I tem • the l ast day of therapy tr eat ment. ter Z0150A), which begins the day af See Section 2.7 and Chapter 4 f or requ irements for CAA process and car • lan e p completion. and End of OM RA and Significant Correction to Prior Q uarterly Start Therapy ent Asses sm t and End of Therapy OMRA and OB RA Quarterly ent. See Star • Assessm End of Therapy OM Start Di scharge Assessment and RA and OBRA OMRA- Start of Therapy and OBRA Dischar ge item set. • • A2300) must be se t f or the day of discharge (Item A2000) and the date of ARD (Item dischar all w ithin 5–7 days af ter the s tart of therapy (I tem O0400A5 or O0400B5 ge must f est) and 1–3 days af la st day ther apy was furnished or O0400C5, whichever is earli ter the O04 00A6 or O0400B6 or O0400C6). The ARD must be set by no more than t wo (Item urther c fter days a charge. (Se e Section 2.8 f or f the date of lari ficatio n.) dis • Co vices sive Ser Plus Exten m or pleted t o clas sif y a resident into a RUG -IV Rehabi lita tion Rehabil itation group ( Z0100A ) and into a non-ther apy group (I tem Z0150A) w hen Item ll s to the resident continue -level s ervi ces af ter the discontinuation of a need Part A SNF therapies. If the RUG -IV clas sif ication (Item Z0100A) is not a ther apy g roup, the assessm ent will not be a ccepted by CMS and cannot be used for Medic are bi lling. sif ication and Medic • lishes a new non-t herapy RUG clas Estab are pay ment rate (I tem Z0150A), which begins the day af ter the l ast day of therapy tr eat ment. • Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD. Change of Therapy OM RA and OBRA A dmission Assessment • set. Comprehensive i tem • A2300) must be set on day 14 or earl ier afte r ad mission and be on the l ast ARD (Item Z0500B) by day 14 a C day of serva tion pe riod. Must be co mpleted (Item OT 7 -day ob af ter ad mission (adm ission date plus 13 calend ar days). • Completed when the pat ient rece ived skill ed th erapy ser vic es and a change of therap y evalu mines t hat a COT O MRA is necessary, b ased on a det ermination tha t the ation deter inten sity of therapy ( as indicat ed by the t otal re imbursable t herapy minutes (RTM) es deliv apy qualifie rs such as n umber of ther apy days a nd disciplin ered and other ther providing therapy), in the COT observation window di ffered from the th erapy i ntens ity t he RUG IV that ory would change. categ on the la st P PS assessment to such an extent 2- 76 October 2018 Page

100 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: • lishes a new RUG -IV clas sif ication and Me dica re pay ment r ate ( Item Z0100A), Estab ainder he rem which begins on Day 1 of that COT observation period and continues for t of the current payment period, unless the paym ent is modified by a subsequent COT OMRA or other unscheduled PPS as sess ment. See Section 2.7 and Chapter 4 f • irements for CAA process and car e p lan or requ completion. Therapy RA and OBRA Quarterly Assessment Change of OM Quarter ly item set as required by the State. • ARD (Item A2300) must m eet the r equirem ents for an OBRA Quarter ly a ssessm ent as • -day observation period. descri bed in Section 2.6 and be on the last day of a COT 7 Completed when the pat ient ived skill ed th erapy ser vic es and a change of therap y rece ation deter ased on a det hat a COT O MRA is necessary, b evalu ermination tha t the mines t sity of inten as indicat ed by the t otal re imbursable t herapy minutes (RTM) and therapy ( other therapy qualifie rs such as number of therapy days and disci plin es p roviding ast therap the therapy i nte nsity on the l ffered from y), in the COT observation window di PPS assessment to such an extent t hat the RUG IV categ ory would change. Item Z0100A), Estab lishes a new RUG -IV clas sif ication and Me dica re pay ment r ate ( • ainder which begins on Day 1 of that COT observation period and continues for t he rem the paym of the current payment period, unless ent is modified by a subsequent COT OMRA or other unscheduled PPS as ment. sess • or OB RA Quarterly assess ment co mpletion requirem ent s. See Section 2.6 f The Change of rapy OM RA and Annual Assessment • Comprehensive i tem set. ent as • ARD (Item A2300) must m eet the r equirem ents for an OBRA Annual ass essm descri bed in Section 2.6 and be on the last day of a COT 7 -day observation period. y • Completed when the pat ient rece ived skill ed th erapy ser vic es and a change of therap MRA is necessary, b t the ermination tha evalu ation deter mines t hat a COT O ased on a det inten therapy ( as indicat ed by the t otal re imbursable t herapy minutes (RTM) and sity of other therapy qualifie rs such as the number of therapy days and disciplines providing ast therap ffered from the therapy i nte nsity on the l y), in the COT observation window di PPS assessment to such an extent t hat the RUG IV categ ory would change. lishes • Estab -IV clas a new RUG sif ication and Me dica re pay ment r ate ( Item Z0150A), which begins on Day 1 of that COT observation period and continues for t ainder he rem of the current payment period, unless the paym ent is modified by a subsequent COT OMRA or other unscheduled PPS as sess ment. See Section 2.6 f or OB RA Annual assess ment co mpletion requirem ents. • irements for CAA process and car e p lan • See Section 2.7 and Chapter 4 f or requ completion. 2- 77 October 2018 Page

101 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Change of RA and Significa nt Change in Status Assessment Therapy OM Comprehensive i set. • tem ARD (Item t within 14 days after the d etermination th at the cri teria are • A2300) must be se or a S igni ficant C hange in St atus assessm met f and be on the last day of a COT 7 -day ent observation period. pleted ( Item Z0500B) within 14 da ys a fter t he ARD and within 14 days af ter • Must be com ermination the det the cr iteria a re m et for a Signif icant C hange in Stat us assessm ent. that y • Completed when the pat ient rece ived skill ed th erapy ser vic es and a change of therap evalu hat a COT O MRA is necessary, b ased on a det ermination tha t the mines t ation deter sity of therapy ( as indicat ed by the t otal re imbursable t herapy minutes (RTM) inten ered and other ther apy qualifie rs such as the number of therapy days and discipli nes deliv ntens in the COT observation window di ffered from the th erapy i ity providing therapy), on the la PS assessment to such an extent that t he RUG IV categ ory would change. st P • Estab lishes a new RUG -IV clas sif ication and Me dica re pay ment r ate ( Item Z0150A), which begins on Day 1 of that COT observation period and continues for t he rem ainder of the current payment period, unless the paym ent is modified by a subsequent COT OMRA or other unscheduled PPS as sess ment. and Chapter 4 • See Section irements for CAA process and car e p lan for requ 2.7 completion. Change of The OM RA and Significa nt Correcti on to Prior Comprehe nsive rapy sm ent Asses • Comprehensive i tem set. • ARD (Item A2300) must be se t within 14 days after the d eterm ination th at an uncorre cted error in the prior co sess ment has occur red and be on the last day of a mprehensive as COT 7 -day observation period. ter Must be com pleted ( Item Z0500B) within 14 da ys a fter t he ARD and within 14 days af • the det ermination that the cr iteria a re m et for a Signif icant C orre ction a sse ssm ent. y • therap es and a change of Completed when the pat ient rece ived skill ed th erapy ser vic evalu hat a COT O MRA is necessary, b ased on a det ermination tha t the mines t ation deter sity of therapy ( otal ed by the t inten re imbursable t herapy minutes (RTM) and as indicat other therapy qualifie rs such as the number of therapy days and disciplines providing therap y), in the COT observation window di ffered from the therapy i nte nsity on the l ast PPS assessment to such an extent t hat the RUG IV categ ory would change. Item Z0150A), • Estab lishes a new RUG -IV clas sif ication and Me dica re pay ment r ate ( which begins on Day 1 of that COT observation period and continues for t he rem ainder of the current payment period, unless the paym ent is modified by a subsequent COT OMRA or other unscheduled PPS as sess ment. e p lan irements for CAA process and car • See Section 2.7 and Chapter 4 f or requ completion. 2- 78 October 2018 Page

102 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: Change of RA and Significa nt Correcti on to Prior Quarterly Therapy OM sm ent Asses See COT OMRA and O BRA • erly Assessm ent. Quart Therapy OM RA and OBRA Discharge Change of ent Assessm • COT OMR A and OBRA Discharge i tem set. A2300) must be se • t f or the day of discharge (Item A2000) and be on the last ARD (Item day of OT 7 -day ob serva tion pe riod. The ARD must be set by no more than two days a C af ter the dat e of dischar ge. (See Section 2.8 f or f urther cl arifi cation .) • ient rece ived skill ed th erapy ser vic es and a change of therap y Completed when the pat ation deter MRA is necessary, b hat a COT O evalu ased on a det ermination tha t the mines t sity of inten as indicat ed by the t otal re imbursable t herapy minutes (RTM) and therapy ( other therapy qualifie rs such as the number of therapy days and disciplines providing ast therap the therapy i nte nsity on the l ffered from y), in the COT observation window di PPS assessment to such an extent t hat the RUG IV categ ory would change. • Estab lishes a new RUG -IV clas sif ication and Me dica re pay ment r ate ( Item Z0150A), which begins on Day 1 of that COT observation period and continues for t he rem ainder of the current payment period, unless the paym ent is modified by a subsequent COT ment. sess OMRA or other unscheduled PPS as • pleted ( Item Z0500B) within 14 da ys a fter t he ARD. Must be com 2.13 Factors Impacting the SNF Medicare Assessment 8 Schedule Expires Before or O n the Eighth Day of SNF Stay Resident If the benefi in the SNF or while on a l eave of abs ence bef ore or on the e ighth day of ciary dies the cov ered SNF stay, the provide r should prepare a Med icare- req uired assessm ent as co mpletely as possi it the assess ment as req uired. If there is not a PPS MDS in the QIES ASA P ble and subm syste m, the provider must bil l the def ault r ate for any Medicare days. The Medica re Short Stay Policy m ay apply (s ee Chapter 6, Section 6.4 for grea ter d etail). The pro vider m ust al so co mplete aci a Death in F or grea lity T rack ing Record ( see Section 2.6 f ter det ail). Resident Transfers or Discharged Before or On the Eighth Day of SNF Stay Is (e.g., trans ciary isc If the benefi rom the SNF or the Medicare Part A stay ends is d fer red harged f to another payer source) before or on the eighth day of the covered SNF stay, the pro vider should prepar e a Medica re-req uired assess ment as co mplete ly as possi ble and subm it the ass essm ent as requ there is not a PPS MDS in the QIES AS AP syste m, the provider must bil l the def ault ired. If ra te for any Medicare days. The Medicare Short S tay Policy m ay apply (s ee Chapter 6, S ection 6.4 for gre ater det ail). 8 ing bed id ers. prov y to sw Th ese r equir em ents/ polici es also a ppl 2- 79 October 2018 Page

103 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: When the Medicare Part A stay ends on or before the eighth day of the covered SNF stay, and the beneficiary remains in the facility, a Part A PPS Discharge assessment is required. arged f the SNF, the provider must also co mplete an OBRA ciary is disch rom When the benefi ge assess ment Disc har , but if the Medicare Part A stay ends on or before the eighth day of the and the beneficiary is physical ly discharged from the facility the day of or the covered SNF stay day after the Part A stay ends, the Part A PPS and OBRA Discharge assessments may be ee Sections 2.11 and 2.12 for deta ils on combining a Me dic are -requ combined. (S assessm ent ired with a D sessment.) ischarge as Stay Short ciary dies, is dischar ged from the S NF, or dischar ged from Pa If the benefi el of care on or rt A lev bef ore the ei ghth day of covered SNF stay, the r esident m ay be a candi date for the short s tay policy. The short s tay p olicy a llows t he assign ment into a Rehabi lita tion Plus Exten sive Servi ces or Rehabi litation c ory when a r esident rec eived rehabilitation therapy and was not able to ateg eiv Medicare Par t A. See Chapter 6, Section have rec ed 5 days of therapy due to discharge from or grea ter det 6.4 f ail. Resident I s Admitte d to an Acute Care Facility and Returns If a Medicar e Part A re sident is ad mi tted to an ac ute ca re f aci lity and la ter retur ns to the SNF (even if tay fa cility i s le ss than 24 hour s and/or not over m idnight) to resu me Part A the acute s coverage, the Medi care assessment schedule is r esta rted. For all providers, including Swing bed providers , the first re quired Medic are as sess ment is ssm Day asse A0310B = 01) as long as the resident is ent (Item alwa ys the Medic are-r equ ired 5- el igi ble for Medic are Part A re servi led servi ces and has days ceives s kil ces, requires and remaining in the benef it period. Resident I re Facilit y, Not in SNF over M idnight, and I s Not s Sent to Acute Ca to Acute Care Facili ty Admitted dent is out of the f ity over If a resi a midnight, but f or less than 24 hour s, and is not ad mitted acil to an acute c aci lity, the Medi care assessm ent schedule is not res tarted. However, there a re are f ent was absent f ent im ation s: the day pre ceding the midnight on whi ch the r esid paym rom the plic nursing home is not a covered Part A day. This is known as the “midnight rule.” The Medica re assessm ent schedule must then be ad justed. The day prece ding the midnight is not a covered Part Medica A day and therefore, the re as sessm ent cl ock is adjusted by skipping that day in calcula ting when the ne icare assessm ent is due. For e xample, if the resi dent g oes to t he xt Med ergency ro day, day 22 of his Part A stay, and returns at 3 a.m. the next ednes em om at 10 p.m. W his return Wednesday is not bill t A. As a re day, of able to Par to the SNF, Thursday, sult, the day beco mes day 22 of his Part A stay. Resident Takes a Lea ve of Absence from t he SNF If a resi is out of the f acil ity f or a Leave of Absence (L OA) as def ined on page 2-13 in this dent chapt er, the Medica re as sess ment schedule may be adjus ted f or cer tain as sessments. For scheduled PPS assess ments , the Me dicar e asses sm ent schedule is adju sted to ex clude the LOA esident le ment. For example, if a r or a given assess aves when determining the appropria te A RD f 2- 80 October 2018 Page

104 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: a SNF at 6:00 ident’s s tay a nd retur ns to the SNF the res pm on Wednesday, which is Day 27 of mes a non-bi llable day and Thursday be comes Day ednesday beco on Thursday at 9:00am, then W iden t’s s tay. Therefore, a f acil ity th at would choose Day 27 for the ARD of thei r 30 - 27 of the res day assessment would se lect Th ay as the ARD date r ather than W ednesday, as Wednesday is ursd able Medica day. no longer a bill re Part A ase of unschedul ed PPS assessments , the ARD of the relevant assess ment is not a In the c ffected by the LOA because the ARDs for unscheduled assessm ents are not tied dire ctly to the Medi care assessm ent calend ar or t o a par ticu lar day of the reside nt’s stay. For ins tance, Day 7 of the COT observation period oc curs 7 days following the ARD of the m cent P PS assessment used f or ost re s if nt during the COT observation period. For payment, regardles a LOA occurs at any poi for a resi den t’s 30- day ass example, if the ARD ent were set for November 7 and the essm resident we nt to the em ergency room at 11:00pm on November 9, returning on November 10, Day 7 of the COT observation pe riod would remain November 14. Moreover, a SN F may use a date out side the SNF P art A Medi care Benef it ( i.e., 100 days) as the ARD unschedule d PPS a sse ssment, but only in the case where t he ARD for the for an unscheduled assessm ent falls on a da y that is not counted among the beneficiar y’s 100 days due to a l eave of absence (LOA), as def ined above, and the resident ret urns to the facil ity from the observation period oc art A. For example, Day 7 of the COT re P curs 7 days LOA on Medica following the ARD of the m ost recent PPS a ment used for payment, reg ard less if a LOA ssess nt during t If the ARD for a resi dent’s 30 -day occurs at any poi he COT observation period. ent were s et for November 7 and the resident we nt to the em ergency room assessm at 11:00pm on Nov ember 14, returning on November 15, Day 7 of the COT observation period would rem ain Nov ember 14 for purposes of cod ing the COT OMRA. Ther e may be cases in which a SNF plans to co led and unsche duled assess ment mbine a schedu on a given day, but then es an L OA day f or the resi dent. In such cases, while that that day becom day m ay sti ll be u sed as the ARD of the unscheduled ass ess ment, this day cannot be us ed as the ARD of the scheduled as sessment. For exam ple if the ARD for a resident’s 5-day assessm ent were s the emergency room at 1:00pm on May 17, et for May 10 and the r esi dent went to day/COT returning on May 18, a f not com plete a co mbined 14- uld OMRA with an lity co aci l have an ARD of May 17, the 14- ARD set for May 17. Rather, while the COT OMRA could stil essment would need to ha ve an ARD that f alls on one of the resident’s M edica re A day ass it days. benef If the beneficiary experiences a leave of absence during part of the assessment observation period, the facility may include services furnished during the beneficiary’s temporary absence (when permitted under MDS coding guidelines; see Chapter 3). Resident Discharg ed from Pa rt A Ski lled Services and Returns to SNF Part A Skilled Level Services In the s itu ation when a benef ici ary’s Medicare Pa rt A stay ends but he/she remains in the f aci lity in a Medi care and/or Me dicaid cer tifi ed bed with another pay er source, the facility must continue and must also with the OB RA schedule from the beneficiary’s original date of admission . There is no reason to change the OB complete a Part A PPS Discharge assessment RA schedule 2- 81 October 2018 Page

105 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: when Part A benef me. If the Medi care Part A benef its resu me, the Medicar e schedu le its r esu ain with a 5 -Da y Medic are-requir ed as sess ment, MDS Item A0310B = 01. See Chapter sta rts ag or great er detai l to d eter mine whether or not the resi dent is eli gible for Part A 6, Section 6.7 f SNF coverage. date of ent A1 600) is r etained. The benef iciary sh ould be ass essed to The original ry (Item mine if there was a signi ficant c deter tatus. A SCSA could be com pleted wi th eith er the hange in s Medica re-required 5-day or 14- day a ssessm ent or separ ately. Resident Discharg ed from Pa rt A Ski lled Services and Is Not Physically Discharged from the Skilled Nursing Facility In the situation when a resident but the resident is not physically ’s Medicare Part A stay ends aci , the Part A PPS Discharge assessment is required. If the Medi care discharged from the f lity its resu Part A benef e schedu le sta rts ag ain with a 5 -Da y Medic are-requir ed me, the Medicar assess ment, MDS Item A0310B = 01. See Chapter 6, Section 6.7 f or great er detai l to d etermine whether or not the resi eli gible for Pa rt A SNF coverage. dent is Delay in Requiring and Receiving Skilled Services There ar e instances wh en the bene ficiary d oes not req uire S NF level of care s erv ices when init ially ad mitted to the SNF. See Ch apter 6, Section 6.7. Non -Com pliance w ith the PPS Assessment Schedule at ent th ion 413.343, an assessm tion (CFR) Sect According to Part 42 Code of Feder al Regula does not have its ARD within the p aid at the def ault rate for the rescribed A RD window will be p Frequent ear ate ass ess ment scheduling pliance. ly or l number of days the ARD is out of com ay resu lt in a pract ault r ate t akes the pla ce of the otherwise ap pli cable ices m review. The def ra te. It is equal to the r ate p owest acu lecting the l Federal ity level, and aid for the RUG group ref would gener lowe r than the M edica re r ate payable if the SNF had subm itted an assessm ent ally be ce with the pr in accordan bed as sess ment schedule. escri A Early PPS sse ssm ent An assessment should be co mpleted accor ding to the Medicare- req uired assessment schedule. If ormed ear an assessm ent is perf lier than the sc hedule ind icates (the ARD is not in the defined window), the provider w ill be paid at t ate for the number of days the assess ment was he default r mple, a Medi ired 1 4-Day asses sm ent with an ARD of day 12 out of compliance. For exa care- requ ay earl y) would be paid at the def (1 d rate for the fi rst day of the pay ment period that begins ault on day 15. In the c ase of an early C OT OM RA, the early COT would reset the COT calend ar such that the next COT OMRA, if deem ed necessary, wou ld have an ARD set for 7 days f rom t he early COT ARD. For cility co mpletes a 3 0-da y assessment with an ARD of Nov ember 1 which example, a fa clas sif ies a resident into a ther apy RUG. On Nove mber 8, which is Day 7 of the COT observation period, it is deter hat a COT is requi red. A COT OMR A is co mpleted for this mined t resident with a n ARD set for Nov ember 6, which is Day 5 of the COT observation period as opposed to November 8 which is Day 7 of the COT observation period. This COT OMR A would ent w sessm ould be as be consider ed an early assessment and, based on the ARD set for this e arly 2- 82 October 2018 Page

106 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: paid s assessment was out of com pliance. The next seven at the def ault rate for the two days thi 7, and end on November 13. ber day COT observation period would begin on Novem PPS Asse ssm ent Late t the ARD within the def ined ARD window for a Medi If the SNF fails ed to se care-requir ment, including the grace da ys, and the r esi dent is sti ll on Part A, the SNF must co mplete a assess sess ment. The ARD can be no ear lier than the day the e late as id entif ied. rror was If the ARD te a ssessm ent is set f or pri or to the end of the peri od during which the on the la essment would have contr ayment, late ass had the ARD been set tim ely, and/or no olled the p ing assessm ents have occurred, the S NF will bill the default rate f or the number of interven days that th e asses sme nt is out of c ompliance. This is eq ual to t he nu mber of days between the day following the la st day of vaila ble ARD window (including gra ce days wh en appropriate) the a ate ARD (including the late The SNF would then bill the Hea lth Insurance and the l ARD). ve Payment System (HI PPS) code es Prospecti ssment for the tablished by the late asse rem ain ing period of t ime that the assessme nt w ould have contro lle d payment. For example, a Medica re-required 30-da y assess ment with an A RD of Day 41 is out of co mpliance for 8 days and therefore would be paid at the def ault he HIPPS code from the late 3 0- rate for 8 days and t ment until the nex t sched day assess or unscheduled ass essm ent th at con trols payment. In this uled example, if there a re no other a ssess ments until the 60-da y assessment, the remaining 22 days are billed a ding to the HIPPS code on the la te asse ssm ent. ccor A second exampl e, involving a la te unscheduled assessm ent would be if a COT O MRA was completed with an ARD of Day 3 9, while Day 7 of the C OT observation period was Day 37. In te and the f 2 days la fault acility would bill the de this c ase, t he COT O MRA would be consid ered rate for 2 da ys and then PPS cod e f rom the late C OT OM RA until the nex t sched uled bill the HI essment cont ays. NOTE: payment, in this c ase, for at l east 5 d or unscheduled ass In such rols the late e ass ent is c cases where a lat pleted and no intervening assessm ents occur, essm om assessm ent is used to e stablish the C OT calendar. If the ARD of the late as sess ment is set af ter the end of the period dur ing w hich the late assessm ent lled payment, had the as sessm ent been c om pleted timely, or in would have contro an intervening asses sm ent has occurred and the resident i s still on Pa rt A, the cases where provider must stil l co mplete the asse ssment. The ARD can be no earl ier than the day t he err or was iden tified. The S NF must bi ll all cove red days during which the late assessm ent w ould nt had the ARD have controlled payme been set t imely at the default rate reg ardless of the HIPPS code calcul ated late asse ssm ent. For ex ample, a Medicare-requi red 14- day from the would be paid at the def ate for Days 15 through 30. A assessment with an ARD of Day 32 ault r assessm ent cann ot be used to replace a di fferent Medicare- req late assessment. In the uired example above, the SNF would also need to co mplete the 30-day Medi care- requ ired as sessm ent within Days 27-33, which include s g race da ys. The 30 -day a ssessm ent w ould cover Days 31 through 60 a s long as t ici ary has SNF days remaining and is e ligible f or SNF P art A he benef servi this example, the la te 14 -day assessment would not be considered an a sse ssment used ces. In for payment and would not im pact t he COT calend ar, as only an as sess ment used for paym ent can affect the COT calendar ection 2.8). (see s e involving an unscheduled as sessment would be the following. A 30- day A second exampl ent i s co mpleted with an ARD of Day 3 0. Day 7 of the COT observation pe riod is Day assessm ed ti th an ARD s mely for this resident wi et for Day 42 and the 37. An EOT OMRA is per form 2- 83 October 2018 Page

107 CMS’s RAI Version 3.0 Manual CH Assessments for the RAI 2: resident’s vie w of the res ident’s record on Day last day of th erapy was Day 39. Upon further re lity det an mpleted with aci ARD of Day 37 but 52, the f ermines that a COT should have been co or the COT O was not. The ARD f MRA is set for day 52. The late COT OMRA should have controlled pay ment from Day 31 until the next assess ment used for paym ent. Because ther e was rven ing assess ment (in this ca se the EOT OMRA) prior to the ARD of the late COT an inte OMRA, the f acil ld bill the def ault rate for 9 days (the period during which the COT ity wou rol ility would bill the RUG from the E OT OMRA OMRA would have cont led payment). The fac al begin ning the f irst non-ther apy da y, in this case Day 40, until the next scheduled or as per norm unscheduled ass essment used for paym ent. sed P PS Asse ssment Mis If the SNF fails to se t the ARD of a scheduled P PS assessment prior to the end of the last day of re Medica the ARD window, including gra ce days, and the resident was alr eady dis charged f rom NF PPS Part A when this e cannot co mplete an ass essm ent f or S discovered, the provider rror is purposes and the days cannot be billed to Par t A. An existing OB RA assess ment (except a s tand - alone d isch arge ass essment) in the Q IES ASAP s ystem m ay be used to bil l for so me P art A days when speci fic ci rcumstances ar e m et. See Chapter 6, Section 6.8 f or great er detai l. In the c ase of an unscheduled PPS as sess ment, if the SNF f ails to set the A RD for an unscheduled PPS assessment within the def ined sess ment, and the ARD window for that as resident has ged from Part A, the a ssessm ent is missed and cannot be com pleted. All been dischar days th at would have been paid by the m issed assessm ent (had it been com pleted tim ely) a re consider iab le. However, as with t he l ate unscheduled ass essment policy, the ed provider-l essment controls the sts until the p oint w hen an in ter vening ass provider-liable period only la ent. paym sessm Errors on a PPS As ent ct a n error on bm itted to the QIES AS AP syste m, the nursing To corre an MDS that has been su ity must follow the norm al MDS corr ection procedu facil see Chapter 5). res ( *These req uire ments/pol ici es also apply to swing bed provide rs. 2.14 Expected Order of MDS Records The MDS records f or a nursing hom e resident a re expected to occur in a s peci fic or der. For ry rec example, the f for a resi dent is ex pected to be an Ent ecord ord w ith en try type (Item irst r A1700) indi cating ad mission, and the next r ecord is expec ted t o be an ad mission a ssessm ent, a 5 - day PPS assessm ent, a dischar ge, or death in fa cility. The QI ES AS AP s ystem will is sue a d. Exa warning when an unexpected record is sub mitte ent r mples include, an a ssessm ecord a fter a dischar ge ( xpected) or a ny record af ter a dea th in facil ity rec ord. an entry is e et date, r mine the order of rec er than the submission dat e, is used to deter The targ ords. The ath tem et da the ass targ ent refer ence date (I te is A2300) f or assessm ent records, the e ntry d ate essm (Item A16 00) for entry records, and the dis char ge date (I tem A2000) for discharg e or death in facil ords. In the following t able, the p rior r ecord is re presented in the colu mns and the next ity rec (subsequent) record is re presen ted in the rows. A “no” has bee n placed in a cell when the next record is not expected to follow the prior record; t he QIES A SAP system will is sue a r ecord that the next tain a “no ates .” A blank cell indic order war ning f or reco rd co mbinations that con 2- 84 October 2018 Page

108 CMS’s RAI Version 3.0 Manual 2: Assessments for the RAI CH record is e xpected to f ollow the pr ior rec ord; a r ecord or der warning wi ll not be issu ed f or these combinations. S 2.0 record ast MD ober 1, 2010, the l fter Oct For the f irst MDS 3.0 record with e vent da te on or a o deter AP vaila ble) sh ould be used t (if a mine if the record order i s ex pected. The QIES AS will f st MDS 2.0 record and i is system wo records ind the la r of these t ssue a warni ng if the orde unexpected. Note that or Swing Bed MDS t here a re not a ny QIES A SAP record order warni ngs produced f records. 2-85 October 2018 Page

109 October 201 CMS’s RAI Version 3.0 Manual Expected Order of MDS Records Prior Record 8 PPS OMRA/ Death Part A PPS PPS PPS Clinical OBRA PPS OBRA OBRA PPS OBRA in PPS No prior Change 60-day 5-day 14-day 90-day Annual Discharge 30-day Quarterly Admission Entry Discharge Next Record facility record Entry no no no no no no no no no no no no OBRA dmission no no no A no no no no no no OBRA Annual no no no no no OBRA uarterly, sign. Q change, sign no no no correction no no no no no no no PPS 5 -day no no PPS 14 no no no no no no no -day PPS 30 -day no no no no no no no no no PPS 60 -day no no no no no no no no no no no no no PPS 90 -day no no no no PPS CH no no no no nscheduled U 2 OBRA : Assessments for the RAI no no no Discharge P art A PPS no Discharge no no Death in no facility no no Page 2- Note: “no” indicates that the record sequence is not expected; record order warnings will be issued for these combinations. B lank cells 86 no record order warning will be issued for these combinations. indicate expected record sequences;

110 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI 2.15 Determining the Item Set for an MDS Record or a par The item mplet ely de termined by the reason f or assessm ent ticular MDS r set f ecord is co 0310D, A0310 F ). I tem set deter mination is B, A0310C, A , and A0310H Ite ms (A0310A, A0310 ftware f rom C MS and pri vate vend ors will a uto matical ly m ake complicated and standar d MDS so s sec this d anual lookup ta bl es f or deter mining the ite m set when tion provides m eter mination. Thi re is unav aila ble. ftwa mated so auto okup table is f or nursing hom e recor ds. The f irst 4 The f mns are ent ries f or t he reason irst lo colu ent (RFA) It A0310C, A0310F , and A0310H . Item A0310D for assessm ems A0310A, A0310B, change assess een om itted be cause i t will a lways be sk ipped on a nical (swing bed cli ment) has b d. To deter mine the i tem set f or a r ecord, loc ate t he row that i ncludes the nursing hom e recor 10A, A0310B s A03 , and A0310H for th at recor d. W hen the values of Item , A0310C, A0310F ISC and Descrip tem ntif ied in the ated, then the i tion colum ns f or that row. If row is loc set is ide mbina tion of Ite ms A03 10A, A0310 B, A0310C, A0310F , and A0310H values f or t he the co nnot be loc record ca hat co mbinat ion of R FAs is not a llow ed and any ated in any row, then t hat co mbinat ected by t he QIES A SAP syste m. record with t ion will be rej Code (ISC) Reference Table Nursing Home It em Set PPS Entry/ Part A OMRA PPS RFA Discharge OBRA RF A Discharge (A (A 0310B) 0C) 031 0A) (A0310F) 031 (A ISC Description (A0310H) 01, 0 2 , 99 01 0 10, 1 1, 99 0,1 NC C o m p r e h e n si ve 01 01, 0 2 , 07 1,2, 3 10, 1 1, 99 NC C o m p r e h e n si ve 0,1 Co NC 4 01 02, 07 mpre hensive 10, 11,99 0,1 0,1 03 11,99 01 thru 05,99 10, NC Co mpre hensive 0 04,05 3 10, 11,99 0,1 1,2, NC Co mpre hensive 03, 01 thru 07 0,1 4 04,05 11,99 02 thru 05,07 03, NC Co mpre hensive 10, 05 0 10, 11,99 0,1 04, NC Co mpre hensive 01 thru 07,99 02, 06 01 thru 05,99 0 10, 11,99 0,1 NQ Quarterl y NQ 02, 0 1 t h ru 07 1,2, 3 10, 1 1, 99 0,1 06 Q u a rt e r l y 0,1 11,99 4 10, 06 02, 02 thru 05,07 NQ Quarterl y 99 99 0 1 t h ru 0 5 0,1 , 2,3 10, 1 1, 0,1 NP PPS 0,1 NP 99 11,99 10, PPS 4 02 thru 05 07 1 99 0 NS S OT O M R A 99 NSD 07 11 0,1 10, SOT OMRA and Disc harge 1 99 07 2,3, 4 99 0 NO EO T, EOT-R or COT OMRA 99 0,1 2,3, 4 10, 11 99 07 NOD EO T, EOT-R or COT OMRA and Disc harg e ND 99 10, 11 0,1 99 0 OBRA Disc harge 0 0 01, 12 ing 99 NT Track 99 1 99 99 0 NPE Part A PPS Discharge 99 Consider e xamples of t he use of this table. If Items A0310A = 01, A0310B = 99, A0 310C = 0 , = 0 (a st andalone OBRA Adm n these ent), the ission assessm Item A0310 F = 99 , and A0310H 87 October 2018 Page 2-

111 CMS’s RAI Version 3.0 Manual CH 2: Assessments for the RAI prehensive a set is an OBRA c om tem ssessm ent (NC ). The va lues are m atched in row 1 and the i ected if Item A0 310F is chan ged to 10 (a dm issi on assessm ent com bined same row would be sel return n with a nti cipated dischar ge as sessm ent). The item set i s again an O BRA ot a prehensive as sess ment (NC). If Ite ms A0310A = 99, A0310B = 99, A0310C = 0 , Item com A0310F = 12 , and A0310H = 0 (a deat h in f aci lity tracking recor d), then these v alues are matched in the last tem set is a t racking rec ord (NT). Finally, if Items A031 0A = 99, r ow and the i A0 0310C = 0 , A0310F = 99, and A0310H = 0, then no row m atches these ent ries, 310B = 99, A and the r ecord is inva lid and would be re jected. r equest r There is o tional i tem set f or inacti vation ne addi ecor ds. This is the set of ite ms acti ve on SAP syste equest vation r m. An inacti a reques t to inact iva te a record in the nationa l M DS QIES A rd is “In is ind set f or t his t ype of reco ed by A0050 = 3. The item activation” w ith an ISC code icat of XX. he f okup table is f or swing bed records. T eason f irst 5 c olum ns are en tries f or t he r The next lo or assessm ent ( RFA) Ite ms A0310A, A 0310B, A0310C, A0310D, A0 310F , and A0310H . To 10A, det ermine the item set f or a rec ord, loc ate t he row that in cludes the val ues of Ite ms A03 , and A0310H ow is loc A0310B , A0310C, A 0310D, A0310F f or that record. W hen the r ated, the co then the m set is iden tified in the ISC and Descrip tion colu mns for that row. If ite mbination of A03 10A, A0310B, A 0310C, A0310D, A 0310F , and A0310H values f or the recor d cannot be locat ed in a ny row, then tha t com bination of R FAs is not a llowed a nd any record with th at SAP syste com ill be rej ected by t he QIES A bination w m. Swing Bed Item S et Code (ISC) Reference Ta ble Part A SB Cli tr y/ nical En Discharge Change harge Disc RFA O BRA PPS OMRA RFA (A0310H) 031 0D) (A 031 0F) (A 03 1 0 (A A) 0 C) B 10 1 03 (A 03 ) (A p S D e s cr i ti o n I C 01 thru 05 0,1 ,2,3 0 10, 11,99 0,1 SP PPS 99 01 thru 07 ,2,3 1 10, 11,99 0,1 99 SP PPS 0,1 02 thru 05 0 10, 11,99 0,1 SP PPS 99 4 02 thru 05,07 11,99 1 10, 99 0,1 SP PPS 4 07 1 0 99 0 SS SOT OMRA 99 d n a 10, 99 07 1 0 11 0,1 S SD S OT O M R A Disc harge 07 0 99 0 99 2,3,4 EOT, EOT-R or SO COT OMRA 99 07 2,3,4 0 10, 11 0,1 S OD EOT, E O T - R o r COT and OMRA Disc harg e 99 99 0 0 10, 11 0,1 SD Dis c h a r ge 12 99 0 0 01, 99 0 ST Track ing set is al so used f A 0050 = 3. wing beds when Item or s The “Ina ctivation” (XX) item 88 Page 2- October 2018

112 CMS’s RAI Version 3.0 Manual CH 3: Overview of Guide to MDS Items OVERVIEW -BY -ITEM CHAPTER 3: TO THE ITEM GUIDE TO THE MDS 3.0 -by-item coding instructions for all required sections and items in the This chapter provides item comprehensive MDS Version 3.0 item set. The goal of this chapter is to facilitate the accurate coding of the MDS resident assessment and to provide assessors with the rationale and resources to optimize resident care and outcomes. 3.1 Using this Chapter Throughout this chapter, MDS assessment sections are presented using a standard format for tion are available for ease of review and instruction. In addition, screenshots of each sec illustration purposes. Note: There are images imbedded in this manual and if you are using a screen reader to access the content contained in the manual you should refer to the MDS 3.0 item set to review the referenced information. T he order of the sections is as follows: • Intent. The reason(s) for including this set of assessment items in the MDS. • Item Display. To facilitate accurate resident assessment using the MDS, each assessment section is accompanied by screen shots, which display the item from the MDS 3.0 item set. • The purpose of assessing this aspect of a resident’s clinical or Item Rationale. functional status. • Health- related Quality of Life. How the condition, impairment, improvement, or decline being assessed can affect a resident’s quality of life, along with the importance of staff understanding the relationship of the clinical or functional issue related to quality of life. • Planning for Care. How assessment of the condition, impairment, improvement, or decline being ass essed can contribute to appropriate care planning. • Sources of information and methods for determining the Steps for Assessment. correct response for coding each MDS item. • Coding Instructions. The proper method of recording each response, with explanations of individual response categories. • Coding Tips and Special Populations. Clarifications, issues of note, and conditions to be considered when coding individual MDS items. Case examples of appropriate coding for most, if not all, MDS Examples. • sections/ite ms. Additional layout issues to note include (1) the symbol is displayed in all MDS 3.0 sections/items that require a resident interview, and (2) important definitions are highlighted in the columns, and these and other definitions of interest may be found in the glossary. Page 3- October 2018 1

113 CMS’s RAI Version 3.0 Manual CH 3: Overview of Guide to MDS Items Becoming Familiar with the MDS 3.2 -recommended Approach 1. First, reading the Manual is essential. Th e CMS Long -Term Care Facility Resident Assessment Instrument User’s • source of information for completing an MDS assessment. Manual is the primary Notice how the manual is organized . • • Using it correctly will increase the accuracy of your assessments. • While it is important to understand and apply the information in Chapter 3, facilities should also become familiar with Chapters 1, 2, 4, 5 and 6. These Chapters provide the framework and supporting information for data collected on the item set as well as the process for further assessment and care planning. It is important to understand the entire process of the RAI in conjunction with the • intent and rationale for coding items on the MDS 3.0 item set. Check the MDS 3.0 Web site regularly for updates at: • http://www.cms.gov/Medicare/Quality -Initiatives -Patient -Assessment - Instruments/NursingHomeQualityInits/MDS30RAIManual.html . • If you require further assistance, submit your question to your State RAI Coordinator listed in Appendix B: State Agency and CMS Regional Office RAI/MDS Contacts available on CMS’ website: -Assessment -Patient -Initiatives - http://www.cms.gov/Medic are/Quality Instruments/NursingHomeQualityInits/MDS30RAIManual.html . Second, review the MDS item sets. 2. Notice how sections are organized and where information should be recorded. • Work through one section at a time. • • Examine item definitions and response categories as provided on the item sets, realizing that more detailed definitions and coding information is found in each Section of Chapter 3. • There are several item sets, and depending on which item set you are completing, the skip patterns and items active for each item set may be different. 3. Complete a thorough review of Chapter 3. • Review procedural instructions, time frames, and general coding conventions. • Become familiar with the intent of each item, rationale and steps for assessment. • Bec ome familiar with the item itself with its coding choices and responses, keep ing in mind the clarifications, issues of note, and other pertinent information needed to understand how to code the item. • Do the definitions and instructions diffe r from current practice at your facility? • Do your facility processes require updating to comply with MDS requirements? Enter the Complete a test MDS assessment for a resident at your facility. • appropriate codes on the MDS. Page 3- October 2018 2

114 CMS’s RAI Version 3.0 Manual CH 3: Overview of Guide to MDS Items • Make a note where your review could benefit from additional information, training, and using the varying skill sets of the interdisciplinary team. Be certain to e xplore resources available to you. As you are completing this test case, read th rough the instructions that apply to • each s ection as you are completing the MDS. Work through the Manual and item one section at a time . Make sure you set until you are comfortable coding items understand this information before going on to another section. • Review the test case you completed. Woul d you still code it the same way ? Are you surprised by any definitions, instructions, or case examples? For example, do you understand how to code ADLs? you review the coding choices in your test case against the manual, make • As corresponding notations the section(s) of this Manual where you need further to clarification , or where questions arose. Note sections of the manual that help to clarify these coding and procedural questions. • Would you now complete your initial case differently? • It will take time to go through all this material. Do it slowly and carefully without rushing. Discuss any clarifications, questions or issues with your State RAI Coordinator (see Appendix B : State Agency and CMS Regional Office RAI/MDS Contacts available on CMS’ webs ite: - -Assessment -Patient -Initiatives http://www.cms.gov/Medicare/Quality Instruments/NursingHomeQualityInits/MDS30RAIM ). anual.html 4. Use of information in this chapter: Keep this chapter with you during the assessment process. • • Where clarification is needed , review the intent , rationale and specific coding instructions for each item in question. 3.3 Coding Conventions There are several standard conventions to be used when completing the MDS assessment, as follows. , unless otherwise stated. • The standard look- back period for the MDS 3.0 is 7 days • - ), the look With the exception of certain items (e.g., some items in Sections K and O back period does not extend into the preadmission period unless the item instructions state otherwise . In the case of reentry, the look -back period does not extend into time prior to the reentry, unless instructions state otherwise. • When determining the response to items that have a look- back period to the Admission/Entry, Reentry, or Prior OBRA or scheduled PPS assessment, whichever is most recent, staff must only consider those assessments that are required to be submitted to the QIES AS AP system. PPS assessments that are completed for private insurance and Medicare Advantage Plans must not be submitted to the QIES ASAP system and therefore should not be considered when deter mining the “prior assessment.” There are a few instances in whi ch scoring on one item will govern how scoring is • completed for one or more additional items. This is called a skip pattern. The instructions direct the assessor to “skip” over the next item (or several items) and go on to another. p pattern, leave the item blank and move on to the next item as When you encounter a ski Page 3- October 2018 3

115 CMS’s RAI Version 3.0 Manual Overview of Guide to MDS Items CH 3: directed (e.g., item B0100, , directs the assessor to skip to item G0110, Comatose Activities of Daily Living Assistance , if B0100 is answered code 1, yes. The intervening items from B0200- F0800 would not be coded (i.e. left blank). If B0100 was recorded as code 0, no, then the assessor would continue to code the MDS at the next item, B0200). • Use a check mark for boxes where the instructions state to “check all that apply,” if specified condition is met; otherwise these boxes remain blank (e.g., F0800, Staff Assessment of Daily and Activity Preferences , boxes A -Z). Use a numeric response (a number or pre -assigned value) for blank boxes (e.g., D0350, • Safety Notification ). When completing hard cop y forms to be used for data entry, capital letters may be easiest • to read. Print legibly. • When recording month, day, and year for dates, enter two digits for the month and the day and four digits for the year. For example, the third day of January in the y ear 2011 is recorded as: 0 1 0 2 3 0 1 1 Month Year Day • Almost all MDS 3.0 items allow a dash ( -) value to be entered and submitted to the MDS QIES ASAP system. — A dash value indicates that an item was not assessed. This most often occurs when a resident is discharged before the item could be assessed. Dash values allow a partial assessment to be submitted when an assessment is — required for payment purposes. e are four date items (A2400C, O0400A6, O0400B6, and O0400C6) that use a Ther — -filled value to indicate that the event has not yet occurred. For example, if there dash is an ongoing Medicare stay, then the end date for that Medicare stay (A2400C) has d, therefore, this item would be dash- not occurre filled. — The few items that do not allow dash values include identification items in Section A [e.g., Legal Name of Resident (Item A0500), Assessment Reference Date (Item A2300), der (Item A0800)] and ICD diagnosis codes Type of Assessment (Item A0310), and Gen (Item I8000). All items for which a dash is not an acceptable value can be found on the CMS MDS 3.0 Technical Information web page at the following link: -Initiatives - -Patient-Assessment http://www.cms.gov/Medicare/Quality Instruments/NursingHomeQualityInits/N HQIMDS30TechnicalInformation.html . • When the term “phys ician” is used in this manual, it should be interpreted as including s, if allowable under nurse practitioners, physician assistant s, or clinical nurse specialist and Medicare. state licensure laws Resid • ents should be the primary source of information for resident assessment items. Should the resident not be able to participate in the assessment, the resident’s family, d. significant other, and guardian or legally authorized representative should be consulte • Several times throughout the manual the word “significant” is used. The term may have different connotations depending on the circumstance in which it is used. For the MDS 3.0 , the term “significant” when discussing clinical, medical, or laboratory findings 4 Page 3- October 2018

116 CMS’s RAI Version 3.0 Manual Overview of Guide to MDS Items CH 3: refers to measures of supporting evidence that are considered when developing or assigning a diagnosis, and therefore reflects clinical judgment. When the term ,” “significant” is used in discussing relationships between people, as in “significant other it means a person, who may be a family member or a close friend that is important or influential in the life of the resident. When complet ing the MDS 3.0, there are some items that require a count or • ever, there are instances where the actual results of the count or measurement, how measurement are greater than the number of available boxes. For example, number of pressure ulcers, or weight. When the result of a count or measurement is greater than the number of available boxe s, facilities are instructed to maximize the count/measurement by placing a "9" in each box (e.g., for item K 0200B , if the weight was 1010 lbs , you would enter 999 in the available boxes). Even though the number is not exact, the facility should document the correct number in the res ident's medical record and ensure that an appropriate plan of care is completed that addresses the additional counts/measurements. Section Title Intent Obtain key information to uniquely identify each resident, nursing Identification Information A home , type of record, and reasons for assessment. Document the resident’s ability to hear, understand, and communicate Hearing, Speech, and , hearing or visual with others and whether the resident experiences B Vision and/ or difficulties. speech limitations Determine the resident’s attention, orientation, and ability to register Cognitive Patterns C and recall information . signs and symptoms of mood distress D Mood Identify . Identify behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive Behavior E to facility residents, staff members or the environment. Obtain information regarding the resident’s preferences for his or her Preferences for Customary F Routine and Activities daily routine and activities . Assess the need for assistance with activities of daily living ( ), ADLs Functional Status G altered gait and balance , and decreased range of motion. Functional Abilities and care and mobility activities. - the need for assistance with self Assess GG Goals the use of bowel and bladder appliances, the Gather information on use of and response to urinary toileting programs, urinary and bow el H Bladder and Bowel , and bowel patterns. continence, bowel training programs Code diseases that have a relat ionship to the resident’s current Active Diagnose s functional, cognitive, mood or behavior status, medical treatments, I nursing monitoring , or risk of death. Document health conditions that impact the resident’s functional status J Health Condi tions and quality of life. Swallowing/Nutritional Assess conditions that could affect the resident’s ability to maintain K Status adequate nutrition and hydration. Oral/Dental Status . R ecord any oral or dental problems present L Document the risk, presence, appearance, and change of pressure ulcers as well as other skin ulcers, wounds or lesions . Also includes Skin Conditions M treatment categories related to skin injury or avoiding injury. Record the number of days that any type of injection, insulin, and/or N Medications select medications was received by the resident . that the and pro Special Treatments , Identify any special treatments, pro cedures, grams O resident received during the specified time periods. Procedures , and Programs October 2018 Page 3- 5

117 CMS’s RAI Version 3.0 Manual Overview of Guide to MDS Items CH 3: Title Intent Section Record the frequency that the resident was restrained by any of the P Restraints and Alarms ; record the frequency listed devices at any time during the day or night that any of the listed alarms were used . Record the participation of the resident, family and/or significant others Participation in Assessment Q in the assessment, and to understand the resident’s overall goals. and Goal Setting D ocument triggered care areas, whether or not a care plan has been a Assessment Care Are developed for each triggered area, and the location of care area V (CAA) Summary assessment documentation. record already present in the QIES R a equest to modify or inactivate X Correction Request ASAP database . rovide billing information and signatures of persons completing the P Z Assessment Administration assessment. Page 3- October 2018 6

118 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH : IDENTIFICATION INFORMATION SECTION A intent of this section is to obtain key information to uniquely identify each Intent: The resident, the home in which he or she resides, and the reasons for assessment. A0 050: Type of Record Coding Instructions for A0050, Type of Record Code 1, Add new record: • new record that has not been previously if this is a submitted and accepted in the QIES ASAP system. If this item is , continue to coded as 1 100 Facility Provider Numbers. A0 If there is an existing database record for the same resident, the same facility, the same reasons for assessment/tracking, and the same date (assessment reference date, entry date, or discharge date), then the current record is a duplicate and not a new record. In this case, the submitted record will be rejected and not accepted in the QIES ASAP system and a “fatal” error will be reported to the facility on the Final Validation Report. if this is a Code 2, Modify existing record: the MDS items for a request to modify • record that already has been submitted and accepted in the QIES ASAP s ystem. If this item is coded as 2 , continue to A0100, Facility Provider Numbers. When a modification request is submitted, the QIES ASAP System will take the following steps: 1. The system will attempt to locate the existing record in the QIES ASAP databas e for this facility with the resident, reasons for assessment/tracking, and date (assessment reference date, entry date, or discharge date) indicated in subsequent Section X items. 2. l be rejected If the existing record is not found, the submitted modification record wil and not accepted in the QIES ASAP system. A “fatal” error will be reported to the facility on the Final Validation Report. 3. If the existing record is found, then the items in all sections of the submitted modification record will be edited. I f there are any fatal errors, the modification record will be rejected and not accepted in the QIES ASAP system. The “fatal” error(s) will be reported to the facility on the Final Validation Report. 4. If the modification record passes all the edits, it will replace the prior record being modified in the QIES ASAP database. The prior record will be moved to a history file in the QIES ASAP database. -1 Page A October 2018

119 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A0050: Type of Record (cont.) • Code 3, Inactivate existing record: if this is a request to inactivate a record that already has been submitted and accepted in the QIES ASAP system. If this item is , skip to X0150, Type of Provider. coded as 3 When an inactivation request is submitted, the QIES ASAP system will take the following steps: 1. The system will attempt to locate the existing record in the QIES ASAP system for this facility with the resident, reasons for assessment/tracking, and date (assessment reference date, entry date, or discharge date) indicated in subsequent Section X items. 2. If the existing r ecord is not found in the QIES ASAP database, the submitted inactivation request will be rejected and a “fatal” error will be reported to the facility on the Final Validation Report. 3. All items in Section X of the submitted record will be edited. If there are any fatal errors, the current inactivation request will be rejected and no record will be inactivated in the QIES ASAP system. 4. If the existing record is found, it will be removed from the active records in the QIES ASAP database and moved to a history file. Identification of Record to be Modified/Inactivated The Section X items from X0200 through X0700 identify the existing QIES ASAP database assessment or tracking record that is in error. In this section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect. This information is necessary to locate the existing record in the database. A MDS assessment for Joan L. Smith is submitted and accepted by the Example: QIES ASAP system. A data entry error is then identified on the previously submitted and accepted record : The encoder mistakenly entered “John” instead of “Joan” when entering a prior assessment for Joan L. Smith. To correct this data entry error, the facility will modify the erroneous record and complete the items in Section X including items under Identification of Record to be Modified/Inactivated. When completing X0200A, the Resident First Name, “John” will be entered in this item. This will permit the MDS system to locate the previously submitted assessment that is being corrected. If the correct name “Joan” were entered, the QIES ASAP system would not locate the prior assessment. The correction to the name from “John” to “Joan” will be made by recording “Joan” in the “normal” A0500A, Resident First Name in the modification record. The modification record must include all items appropriate for that assessment, not just the corrected name. This modification record will then be submitted and accepted into the QIES ASAP system, wh ich causes the desired correction to be made. Page A October 2018 -2

120 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A0100: Facility Provider Numbers Item Rationale DEFINITIONS submitting the • Allows the identification of the facility NATIONAL PROVIDER assessment. IDENTIFIER (NPI) A unique Federal number Coding Instructions that identifies providers of Facilities must have a National Provider Identifier • The health care services. (NPI) and a CMS Certifi cation Number (CCN). NPI applies to the nursing home for all of its residents. provider numbers: Enter the facility • CMS CERTIFICATION A. National Provider Identifier (NPI) NUMBER (CCN) B. CMS Certif ication Number (CCN) Replaces the term State Provider Number (optional). This number is C. “Medicare/Medicaid Provider assigned by the Regional Office and provided to the Number” in survey, certification, and intermediary/carrier and the State survey agency. assessment- related When known enter the State Provider Number in activities. A0100C. Completion of this is not required; however, your State may require the completion of STATE PROVIDER this item. NUMBER Medicaid Provider Number A0200: Type of Provider established by a state. Item Rationale DEFINITION esignation of type of provider. • Allows d SWING BED A rural hospital with less than Coding Instructions 100 beds that participates in • Code 1, nursing home (SNF/NF): if a Medicare the Medicare program that has CMS approval to provide skilled nursing facility (SNF) or Medicaid nursing post -hospital SNF care. The facility (NF). hospital may use its beds, as Code 2, swing bed: if a hospital with swing bed • needed, to provide either approval. acute or SNF care. October 2018 Page A -3

121 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A0310: Type of Assessment For Comprehensive, Quarterly, and PPS Assessments, Entry and OBRA Discharge Records, and Part A PPS Discharge Assessment. Item Rationale • Allows identification of needed assessment content. Coding Instructions for A0310 , Type of Assessment Enter the code corresponding to the reason or reasons for completing this assessment. If the assessment is being completed for both Omnibus Budget Reconciliation Act ( OBRA )– PPS) reasons (A0310B required clinical reasons (A0310A) and Prospective Payment System ( Page A October 2018 -4

122 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A0310: Type of Assessment (cont.) and A0310C) all requirements for both types of assessments must be met. See Chapter 2 on assessment s chedules for details of these requirements . Coding Instructions for A0310A , Federal OBRA Reason for Assessment • Document the reason for completing the assessment, using the categories of assessment types . For detailed information on the requirements for scheduling and timing of the chedules . assessments, see Chapter 2 on a ssessment s • Enter the number corresponding to the OBRA reason for assessment. This item contains 2 digits . For codes 01-06, enter “0” in the first box and place the correct number in the second box. If the assessment is not coded 01-06, enter code “99”. 01. Admission assessment (required by day 14) 02. Quarterly review assessment 03. Annual assessment 04. Significant change in status assessment 05. Significant correction to prior comprehensive assessment Significant correction to prior quarterly assessment 06. None of the above 99. Coding Tips and Special Populations • If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS significant change in status assessment (SCSA) . The nursing home is required to complete a SCSA when they come off the hospice benefit (revoke). See Chapter 2 for details on this requirement. It is a CMS requirement to have a SCSA completed EVERY time the hospice benefit has • been elected, even if a recent MDS was done and the only change is the election of the hospice benefit. Coding Instructions for A0310B, PPS DEFINITION Assessment PROSPECTIVE • Enter the number corresponding to the PPS reason for PAYMENT SYSTEM completing this assessment. This item contains 2 digits. (PPS) For codes 01-07, enter “0” in the first box and place the Method of reimbursement in correct number in the second box. If the assessment is which Medicare payment is not coded as 01-07, enter code “99”. made based on the classification system of that • chedules for detailed See Chapter 2 on a ssessment s service (e.g., resource ing and timing of the information on the schedul utilization groups, RUGs, for assessments. skilled nursing facilities). Page A October 2018 -5

123 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A0310: Type of Assessment (cont.) PPS Scheduled Assessments for a Medicare Part A Stay day scheduled assessment 5- 01. 02. day scheduled assessment 14- 03. day scheduled assessment 30- day scheduled assessment 04. 60- 90- 05. day scheduled assessment Unscheduled Assessments for Medicare Part A Stay PPS 07. Unscheduled assessment used for PPS (OMRA, significant change, or significant correction assessment) 99. None of the above for A03 10C, Medicare Required Coding Instructions PPS Other —OMRA Assessment • Code 0, no: if this assessment is not an OMRA. • Code 1, Start of therapy assessment (OPTIONAL) : with an assessment reference date (ARD) that is 5 to 7 days after the first day therapy services are provided (except when the assessment is used as a Short S tay assessment, see Chapter 6 ). No need to combine with the 5- day assessment except for short stay. Only complete if therapy RUG (index maximized), otherwise the assessment will be rejected. Code 2, E 3 days after the ARD that is 1 to • with an nd of therapy assessment: last day therapy services were provided. Code 3, both the S tart and E nd of therapy assessment: • ARD that is with an that is 1 to 3 days both 5 to 7 days after the first day therapy services were provided and after the last day therapy services were provided (except when the assessment is used as a Short S tay assessment, see Chapter 6) . • Code 4, Change of therapy assessment: with an ARD that is Day 7 of the COT observation period. Coding Instructions for A0310D, Is This a Swing Bed Clinical Change Assessment? Code 0, no: • hange assessment. if this assessment is no t a Swing B ed C linical C • Code 1, yes: if this assessment is a swing bed clinical change assessment. Coding Instructions for A03 10E, Is This As sessment the First , Scheduled Assessment (OBRA PPS , or OBRA Discharge ) since the Most Recent Admission /Entry or Reentry ? if this assessment is not the first s since the most recent • Code 0, no: of these assessment admission/entry or reentry. Page A October 2018 -6

124 CMS’s RAI Version 3.0 Manual 3: CH MDS Items [A] Assessment A0310: Type of (cont.) • Code 1, yes: if this assessment is the first of these assessment s since the most recent admission/entry or reentry. Coding Tips and Special Populations • A0310E = 0 for: o Entry or D eath in Facility tracking records (A0310F = 01 or 12); o A standalone Part A PPS Discharge assessment (A0310A = 99, A0310B = 99, A0310F = 99, and A0310H = 1); or o A standalone unscheduled PPS assessment (A0310A = 99, A0310B = 07, and A0310F = 99). A0310E = 1 on the first OBRA, Scheduled PPS or OBRA Discharge assessment that is • completed and submitted once a faci lity obtains CMS certification. Note: the first submitted assessment may not be the Admission assessment. Coding Instructions for A0310F, Federal OBRA & PPS Entry/Discharge Reporting • Enter the number corresponding to the reason for completing this assessment or tracking record. This item contains 2 digits. For code 01, enter “0” in the first box and place “1” in the second box. If the assessment is not coded as “01” or “10 or “11” or “12,” enter “99”: 01. Entry tracking record DEFINITION Discharge assessment -return not anticipated 10. Discharge Part A PPS 11. -return anticipated Discharge assessment Assessment 12. Death in facility tracking record A discharge assessment None of the above 99. developed to inform current and future SNF QRP Coding Instructions for A0310G, Type of measures and the calculation Discharge (complete only if A0310F = 10 of the se measures. The or 11) A PPS Part Discharge assessment is completed Code 1: if type of discharge is a planned discharge. • when a resident’s Medicare A stay ends , b Part ut the • Code 2: if type of discharge is an unplanned resident remains in the discharge. facility; or may be combined with an OBRA Discharge if Coding Instructions for A0310H, Is this a Part the Part A stay ends on the A PPS Discharge Assessment? same day or the day before the resident’s Discharge Code 0, no: • if this is not a Part A PPS Discharge . Date (A2000) assessment . • if this is a Part A PPS Discharge assessment . Code 1, yes: -7 Page A October 2018

125 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A0310: Type of Assessment (cont.) • A Part A PPS Discharge assessment (NPE Item Set) is required under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) when the resident’s Medicare Part A stay ends (as documented in A2400C, End Date of Most Recent Medicare Stay) but the resident remains in the facility . If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one • , the OBRA Discharge assessment and Part A PPS day before the Discharge Date (A2000) Discharge assessment are both requi red and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000) . A0410: Unit Certification or Licensure Designation Item Rationale t consider Medicare and/or Medicaid status as well as • In coding this item, the facility mus the state’s authority to collect MDS records. State regulations may require submission of -only MDS data to QIES ASAP or directly to the state for residents residing in licensed beds. • wing -bed facilities must be certain they are submitting MDS Nursing homes and s assessments to QIES ASAP for those residents who are on a Medicare and/or Medicaid certified unit. For those residents who are in licensed -only beds, nursing homes must be certain they are submitting MDS assessments either to QIES ASAP or directly to the state in accordance with state requirements. • Payer source is not the determinant by which this item is coded. This item is coded solely according to the authority CMS has to collect MDS data for residents who are on a Medicare and/or Med icaid certified unit and the authority that the state may have to collect MDS data under licensure. Consult Chapter 5, page 5-1 of this Manual for a system discussion of what types of records should be submitted to the QIES ASAP . Steps for Assessment 1. Ask the nursing home administrator or representative which units in the nursing home are Medicare certified, Medicaid certified or dually certified (Medicare/Medicaid) . 2. If some or all of the units in the nursing home are neither Medicare nor Medicaid certified, ask the nursing home administrator or representative if there are units that are state licensed and if the state requires MDS submission for residents on that unit. or licensed by the state, if any. 3. Identify all units in the nursing home that are not certified Page A October 2018 -8

126 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A0410: Unit Certification or Licensure Designation (cont.) Coding Instructions • Code 1, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State: if the MDS record is for a re sident on a unit that is have authority to collect not neither Medicare nor Medicaid certified, and the s tate does MDS information for residents on this unit , the facility may not submit MDS records to QIES ASAP . If any record s are submitted under this certification designation , they will be rejected by the QIES ASAP system . • Code 2, Unit is neither Medicare nor Medicaid certified but MDS data is required by the State: if the nursing home resident is on a unit that is neither Medicare nor Medi caid certified, but the s tate has authority under s tate licensure to collect MDS information for residents on such units, the facility should submit the resident’s MDS records per the state’s requirement to QIES ASAP or directly to the state . -bed facilities. Note that this certification designation does not apply to swing Assessments for swing -bed residents on which A0410 is coded “2” will be rejected by the QIES ASAP system. Code 3, Unit is Medicare and/or Medicaid certified: if the resident is on a • Medicare and/or Medicaid certified unit , regardless of payer source (i.e., even if the resident is private pay or has his/her stay covered under e.g., Medicare Advantage, Medicare HMO, private insurance, etc.), the facility is required to submit MDS records (OB RA and SNF PPS only) to QIES ASAP for these residents . Consult Chapter 5, page 5-1 of this Manual for a discussion of what types of records should be submitted to the QIES ASAP system. A0500: Legal Name of Resident DEFINITION Item Rationale LEGAL NAME • Allows identification of resident. Resident’s name as it . Also used for matching • each of the resident’s records appears on the Medicare If the resident is not card. for Assessment Steps enrolled in the Medicare 1. Ask resident, family, significant other, guardian, or legally program, use the resident’s authorized representative. name as it appears on a Medicaid card or other -issued government document. Page A October 2018 -9

127 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A0500: Legal Name of Resident (cont.) e program, check a 2. Check the resident’s name on his or her Medicare card, or if not in th Medicaid card or other government -issued document. Coding Instructions Use printed letters. Enter in the following order: A. First Name blank; if the Middle Initial (if the resident has no middle initial, leave Item A0500B B. resident has two or more middle names, use the initial of the first middle name) C. Last Name Sr.) Suffix (e.g., Jr./ D. A0600: Social Security and Medicare Numbers Item Rationale Allows identification of the resident. • • Allows records for resident to be matched in system. -10 October 2018 Page A

128 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A0600: Social Security and Medicare Numbers (cont.) Coding Instructions DEFINITIONS Enter the Social Security Number (SSN) in A0600A, • SOCIAL SECURITY one number per space starting with the leftmost space. NUMBER If no social security number is available for the resident A tracking number assigned (e.g., if the resident is a recent immigrant or a child) the to an individual by the U.S. item may be left blank. Federal government for Enter Medicare number in A0600B exactly as it appears • taxation, benefits, and on the resident’s documents. identification purposes. • If the resid ent does not have a Medicare number, a MEDICARE NUMBER Railroad Retirement Board (RRB) number may be (OR COMPARABLE . These RRB numbers contain both letters substituted RAILROAD INSURANCE and numbers. To enter the RRB number, enter the first NUMBER) letter of the code in the leftmost space followed by one An identifier assigned to an letter/digit per space. If no Medicare number or RRB individual for participation in number is known or available, the item may be left onal health insurance nati blank. program. The Medicare For PPS assessments (A0310B = 01, 02, 03, 04, 05, and • Health Insurance identifier may be different from the 07), either the Medicare or Railroad Retirement Board resident’s social security (RRB) number (A0600B) must be present (i.e., may not number (SSN), and may be left blank). Note: A valid SSN should be submitted contain both letters and in A0600A whenever it is available so that resident numbers. For example, many matching can be performed as accurately as possible. residents may receive • A0600B can only be a Medicare number or a Railroad Medicare benefits based on Retirement Board number. a spouse’s Medicare eligibility. A0700: Medicaid Number Item Rationale Assists in correct resident identificatio n. • October 2018 -11 Page A

129 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: (cont.) A0700: Medicaid Number Coding Instructions • Record this number if the resident is a Medicaid recipient. • Enter one number per box beginning in the leftmost box. • Recheck the number to make sure you have entered the digits correctly . • Enter a “+” in the leftmost box if the number is pending. If you are notified later that the resident does have a Medicaid number, just include it on the next assessment. • If not applicable because the resident is not a Medicaid recipient, enter “N” in the leftmost box. Coding Tips and Special Populations • To obtain the Medicaid number, check the resident’s Medicaid card, admission or transfer records, or medical record. me on the MDS matches the resident’s name on the Confirm that the resident’s na • Medicaid card. • It is not necessary to process an MDS correction to add the Medicaid number on a prior . However, a correction may be a State -specific requirement. assessment A0800: Gender Item Rationale . • Ass ists in correct identification • Provides demographic gender specific health trend information. Coding Instructions • Code 1: if resident is male. • Code 2: if resident is female. Coding Tips and Special Populations Resident gender should match what is in the Social Security system. on the MDS • -12 October 2018 Page A

130 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: Date A0900: Birth Item Rationale • Assists in correct identification. • Allows determination of age. Coding Instructions • Fill in the boxes with the appropriate birth date. If the complete birth date is known, do not leave any boxes blank. If the month or day contains only a single digit, fill the first -1918. 02 box in with a “0.” For example: January 2, 1918, should be entered as 01- • Sometimes, only the birth year or the birth year and birth month will be known. These situations are handled as follows: — If only the birth year is known (e.g., 1918), then enter the year in the “year” portion of A0900, and leave the “month” and “day” portions blank. If the birth year and birth month are known, but the day of the month is not known, then enter the year in the “year” portion of A0900, enter the month in the “month” portion of A0900, and leave the “day” portion blank. A1000: Race/Ethnicity Item Rationale This item uses the common u niform language approved by the Office of Management • and Budget (OMB) to report racial and ethnic categories . The categories in this classification are social -political constructs and should not be interpreted as being scientific or anthropological in nature. • Provides demographic race/ethnicity specific health trend information. These categories are NOT used to determine eligibility for participation in any Federal • program. -13 October 2018 Page A

131 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [A] DEFINITIONS A1000: Race/Ethnicity (cont.) RACE/ETHNICITY Steps for Assessment: Interview AMERICAN INDIAN OR Instructions ALASKA NATIVE A person having origins in any 1. Ask the resident to select the category or categories that of the original peoples of North orrespond to his or her race/ethnicity from most closely c and South America (including the list in A1000. Central America), and who maintains tribal affiliation or • Individuals may be more comfortable if this and the community attachment. question are introduced by saying, “We preceding that all our residents get the best want to make sure ASIAN care possible, regardless of their race or ethnic A person having origins in any of the original peoples of the Far your ethnic background. We would like you to tell us East, Southeast Asia, or the and racial background so that we can review the Indian subcontinent including, treatment that all residents receive and make sure for example, Cambodia, China, that everyone gets the highest quality of care” (Baker India, Japan, Korea, Malaysia, et al., 2005). Pakistan, the Philippine Islands, Thailand, Vietnam. If the resident is unable to respond, ask a family member 2. BLACK OR AFRICAN or significant ot her. AMERICAN Category definitions are provided to resident or family 3. A person having origins in any only if requested by them in order to answer the item. of the black racial groups of Afri ca. Terms such as “Haitian” Respondents should be offered the option of selecting 4. or “Negro” can be used in addition to “Black” or “African one or more racial designations. American.” if the resident is unable to respond and no family 5. Only HISPANIC OR LATINO member or significant other is available, observer A person of Cuban, Mexican, identification or medical record documentation may be Puerto Rican, South or Central . used American or other Spanish culture or origin regardless of race. The term Spanish Origin Coding Instructions can be used in addition to Hispanic or Latino. Check all that apply. NATIVE HAWAIIAN OR Enter the race or ethnic category or categories the • OTHER PACIFIC resident , family or significant other uses to identify ISLANDER him or her. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. WHITE A person having origins in any peoples of of the original Europe, the Middle East, or North Africa. -14 Page A October 2018

132 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A1100: Language Item Rationale Health -related Quality of Life • Inability to make needs known and to engage in social interaction because of a language barrier can be very frustrating and can result in isolation, depression, and unmet needs. Language barriers can interfere with accurate assessment. • Planning for Care • When a resident needs or wants an interpreter, the nursing home should ensure that an interpreter is available. e method of communication also should be made available to help to ensure • An alternat that basic needs can be expressed at all times, such as a communication board with pictures on it for the resident to point to (if able). • Identifies residents who need interpreter services in order to answer interview items or participate in consent process. Steps for Assessment Ask the resident if he or she needs or wants an interpreter to communicate with a doctor or 1. health care staff . 2. If the resident is unable to respond, a family member or significant other should be asked. 3. If neither source is available, review record for evidence of a need for an interpreter. 4. If an interpreter is wanted or needed, ask for preferred language. 5. It is acceptable for a family member or significant o ther to be the interpreter if the resident is comfortable with it and if the family member or significant other will translate exactly what the resident says without providing his or her interpretation. Coding Instructions for A1100A • Code 0, no: if the resident (or family or medical record if resident unable to communicate) indicates that the resident does not want or need an interpreter to communicate with a doctor or health care staff. Skip to A1200, Marital Status. • Code 1, yes: ily or medical record if resident unable to if the resident (or fam communicate) indicates that he or she needs or wants an interpreter to communicate with . Specify preferred language. Proceed to 1100B and enter the a doctor or health care staff resident’s preferred language. • if no source can identify whether the resident wants Code 9, unable to determine: or needs an interpreter. Skip to A1200, Marital Status. -15 October 2018 Page A

133 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A1100: Language (cont.) Coding Instructions for A1100B • Enter the preferred language the resident primarily speaks or understands after , observing the resident and listening, and reviewing interviewing the resident and family the medical record. Coding Tips and Special Populations An organized system of signing such as American Sign Language (ASL) can be reported • as the pref erred language if the resident needs or wants to communicate in this manner. A1200: Marital Status Item Rationale Allows understanding of the formal relationship the resident has and can be important for • care and discharge planning. • Demographic information. Steps for Assessment 1. Ask the resident about his or her marital status. 2. If the resident is unable to respond, ask a family member or other significant other. 3. If neither source can report, review the medical record for information. Coding Instructions Choose the answer that best describes the current marital status of the resident and enter • the corresponding number in the code box: 1. Never Married 2. Married 3. Widowed 4. Separated Divorced 5. -16 October 2018 Page A

134 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A1300: Optional Resident Items Item Rationale • Some facilities prefer to include the nursing home medical record number on the MDS to facilitate tracking. • Some facilities conduct unit reviews of MDS items in addition to resident and nursing The unit may be indicated by the room number. home level reviews. • Preferred name and lifetime occupation help nursing home staff members personalize their interactions with the resident. Many people are called by a nickname or middle name throughout their life • . It is important to call residents by the name they prefe r in order to establish comfort and respect between staff and resident . Also, some cognitively impaired or hearing impaired residents might have difficulty responding when called by their legal name, if it is not the name most familiar to them. . For example, a physician Others may prefer a more formal and less familiar address • might appreciate being referred to as “Doctor.” Knowing a person’s lifetime occupation is also helpful for care planning and • conversation purposes. For example, a carpenter might enjoy pursuing hobby shop activities. • These are optional items because they are not needed for CMS program function . Coding Instructions for A1300A , Medical Record Number Enter the resident’s medical record number (from the nursing home medical record, • adm ission office or Health Information Management Department) if the nursing home chooses to exercise this option. Instructions for A1300B , Room Number Coding • Enter the resident’s room number if the nursing home chooses to exercise this option. , Name by Which Resident Prefers to Coding Instructions for A1300C Be Addressed • Enter the resident’s preferred name . This field captures a preferred nickname, middle name, or title that the resident prefers staff use . report or family o Obtained from resident self- r significant other if resident is unable to • respond. -17 October 2018 Page A

135 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A1300: Optional Resident Items (cont.) Coding Instructions for A1300D, Lifetime Occupation(s) Enter the job title or profession that describes the resident’s main occupation(s) before • retiring or entering the nursing home. When two occupations are identified, place a slash (/) between each occupation. • The lifetime occupation of a person whose primary work was in the home should be recorded as “homemaker.” For a resident who is a child or an intellectually disabled adult resident who has never had an occupation, /developmentally disabled record as “none.” A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health -related Quality of Life • All individuals who are admitted to a Medicaid certified nursing facility , regardless of the individual’s payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), (“mental retardation” (MR) in federal regulation) , or related conditions (please contact ntal disability (DD) /developme your local State Medicaid Agency for details regarding PASRR requirements and exemptions). /DD or related conditions may • Individuals who have or are suspected to have MI or ID not be admitted to a Medicaid -certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. A resident with MI or ID • /DD must have a Resident Review (RR) conducted when there is a significant change in the resident’s physical or mental condition. Therefore, when a Significant C tatus A /DD, ssessment is completed for a resident with MI or ID hange in S the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability a uthority (depending on which operates in their State 19(e)(7)(B)(iii) ) in order to notify them of the resident’s change in status. Section 19 1 of the Social Security Act requires the notification or referral for a significant change. 1 1396r(e)(7)(B)(iii). Note that as of this revision date the statute supersedes The statute may also be referenced as 42 USC Federal regulations at 42 CFR 483.114(c), which still reads as requiring annual resident review. The regulation has not yet been updated to reflect the statutory change to resid ent review upon significant change in condition. -18 October 2018 Page A

136 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A1500: Preadmission Screening and Resident Review (PASRR) (cont.) Each State Medicaid A gency might have specific processes and guidelines for referral, • and which types of significant changes should be referred. Therefore, facilities should become acquainted with their own State requirements. Please see https://www.medicaid.gov/medicaid/ltss/institutional/pasrr/index.html • for CMS information on PASRR. Planning for Care The Level II PASRR determination and the evaluation report specify services to be • and/or speci alized services defined by the State. provided by the nursing home • The State is responsible for providing specialized services to individuals with MI or in Medicaid ID /DD. In some States specialized services are provided to residents - certified facilities (in other States specialized services are only provided in other facility types such as a psychiatric hospital). The nursing home is required to provide all other care and services appropriate to the resident’s condition. The services to be provided by the nursing home and/or specialized services provided by • he Level II PASRR determination and the evaluation report the State that are specified in t should be addressed in the plan of care. • Identifies individuals who are subject to Resident Review upon change in condition. Steps for Assessment 1. Complete if A0310A = 01, 03, 04 or 05 (Admission assessment, Annual assessment, hange in S ssessment, S tatus A Significant C ignificant Correction to P rior Comprehensive Assessment). 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. if L Review the PASRR report provided by the State evel II screening was required. 3. Coding Instructions any of the • Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if following apply: — PASRR Level I screening did not result in a referral for Level II screening, or — Level II screening determined that the resident does not have a serious mental illness and/or intellectual/developmental disability or related condition, or equired because the resident was admitted from a hospital PASRR screening is not r — after requiring acute inpatient care, is receiving services for the condition for which he or she received care in the hospital, and the attending physician has certified to require less than 30 days of nursing esident is likely before admission that the r home care. -19 October 2018 Page A

137 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A1500: Preadmission Screening and Resident Review (PASRR) (cont.) • Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. certified • if bed is not in a Medicaid- Code 9, not a Medicaid- certified unit: nursing home. Skip to A1550, Conditions Related to ID/DD Status. The PASRR process does not apply to nursing home units that are not certified by Medicaid (unless a State requires otherwise) and therefore the question is not applicable. — that the requirement is based on the certification of the part of the nursing home Note the resident will occupy . In a nursing home in which some parts are Medicaid certified and some are not, this question applies when a resident is admitted, or transferred to, a Medicaid certified part of the building. A1510: Level II Preadmission Screening and Resident Review (PASRR) Conditions Steps for Assessment Complete if A0310A = 01, 03, 04 or 05 (A dmission assessment, Annual assessment, 1. ssessment, S hange in S tatus A ignificant Correction to P Significant C rior Comprehensive Assessment). 2. Check all that apply. Coding Instructions if resident has been diagnosed with a serious A, • : Code Serious mental illness mental illness. • Code B, Intellectual Disability (“mental retardation” in federal regulation) /Developmental Disability : if resident has been diagnosed with intellectual disability/developmental disability. if resident has been diagnosed with other • Code C, Other related conditions: related conditions. -20 October 2018 Page A

138 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A1550: Conditions Related to Intellectual (ID /DD) Status Disability/Developmental Disability DEFINITIONS Item Rationale SYNDROME DOWN • To document conditions associated with intellectual or A common genetic disorder developmental disabilities. is born with in which a child 47 rather than 46 Steps for Assessment in chromosomes, resulting developmental delays, If resident is 22 years of age or older on the assessment 1. disability, low intellectual dmission reference date, complete only if A0310A = 01 (A muscle tone, other and . assessment) possible effects. AUTISM If resident is 21 years of age or younger on the assessment 2. A developmental disorder reference date, complete if A0310A = 01, 03, 04, or 05 that is characterized by (Admission assessment, Annual assessment, S ignificant interaction, impaired social ignificant Correction to Change in S tatus A ssessment, S and verbal problems with Prior Comprehensive A ssessment). nonverbal communication, or and unusual, repetitive, Coding Instructions limited activities severely and interests. ID Check all conditions related to • /DD status that were present before age 22. EPILEPSY chronic A common • When age of onset is not specified, assume that the is neurological disorder that condition meets this criterion AND is likely to continue characterized by recurrent indefinitely. unprovoked seizures. Code A: if Down syndrome is present. • • if a utism is present. Code B: • pilepsy is present if e Code C: . Code D: if other organic condition related to ID /DD is present. • -21 Page A October 2018

139 CMS’s RAI Version 3.0 Manual MDS Items [A] 3: CH DEFINITION A1550: Conditions Related to Intellectual Disability/Developmental Disability /DD) (ID ORGANIC OTHER Status (cont.) CONDITION RELATED TO ID/DD if an /DD condition is present but the ID • Code E: Examples of diagnostic resident does not have any of the specific conditions conditions include congenital syphilis, maternal listed. intoxication, mechanical Code Z: • /DD condition is not present. if ID at birth, prenatal injury hypoxia, neuronal lipid storage diseases, phenylketonuria (PKU), neurofibromatosis, microcephalus, macroencephaly, meningomyelocele, congenital hydrocephalus, etc. A1600–A1800: Most Recent Admission/Entry or Reentry into this Facility -22 Page A October 2018

140 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A1600: Entry Date Item Rationale DEFINITION • To document the date of admission/entry or reentry into ENTRY DATE . the facility The of admission date initial to the date the , or the facility Coding Instructions recently most resident entry or reentry Enter the most recent date of admission/ • to your facility after returned discharged. being : Month- : XX- -Year Day . Use the format to this facility XX- XXXX. For example, October 12, 2010, would be entered as 10-12-2010. A1700: Type of Entry Item Rationale entry date. Captures whether date i • n A1600 is an admission/entry or re Coding Instructions one of the following occurs: when 1, admission: Code • 1. resident has never been admitted to this facility before ; OR resident has been in this facility previously and was discharged return not anticipated; 2. OR resident has been in this facility previously and was discharged return anticipated and 3. did not return within 30 days of discharge. Code 2, reentry: when all three of the following occurred prior to this entry; the • resident was : admitted to this facility , AND 1. 2. discharged return anticipated, AND 3. returned to facility within 30 days of discharge. -23 Page A October 2018

141 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A1800: Entered From Item Rationale • Understanding the setting that the individual was in immediately prior to facility admission /entry or reentry informs care planning and may also inform discharge planning and discussions. • Demographic information. Steps for Assessment 1. Review transfer and ad mission records. 2. Ask the resident and/or famil y or significant others. Coding Instructions DEFINITIONS -digit code that corresponds to the location or Enter the 2 program the resident was admitted from for this OR PRIVATE HOME admission/entry or reentry. APARTMENT condominium, or Any house, Code 01, community (private home/apt, • community apartment in the board/care, assisted living, group home): if by the owned whether the resident was admitted from a private home, resident or person. another apartment, board and care, assisted living facility or Also included in this category group home. are retirement communities Code 02, another nursing home or swing • for housing and independent the elderly. bed: if the resident was admitted from an institution (or a distinct part of an institution) that is primarily BOARD CARE/ AND engaged in providing skilled nursing care and related LIVING/ ASSISTED services for residents who require medical or nursing GROUP HOME care or rehabilitation services for injured, disabled, or community institutional A non- sick persons. Includes swing beds. that setting residential if the resident was Code 03, acute hospital: • includes services of the admitted from an institution that is engaged in following types: home health providing, by or under the supervision of physicians for services, homemaker/ personal services, or care inpatients, diagnostic services, therapeutic services for meal services. medical diagnosis, and the treatment and care of injured, disabled, or sick persons. October 2018 Page A -24

142 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: (cont.) A1800: Entered From Code 04, psychiatric hospital: if the resident was admitted from an institution that • is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill res idents. • Code 05, inpatient rehabilitation facility (IRF): if the resident was admitted from an institution that is engaged in providing, under the supervision of physicians, services for the rehabilitation of injured, disabled, or sick persons. Includes IR Fs that are units within acute care hospitals. • Code 06, ID/DD facility: if the resident was admitted from an institution that is engaged in providing, under the supervision of a physician, any health and rehabilitative services for individuals who have intellectual or developmental disabilities . • Code 07, hospice: if the resident was admitted from a program for terminally ill persons where an array of services is necessary for the palliation and management of terminal illness and related conditions . The hospice must be licensed by the State as a hospice provider and/or certified under the Medicare program as a hospice provider. Includes community-based or inpatient hospice programs. if the resident from a was admitted • Code 09, long term care hospital (LTCH): -term, acute -care hospital which has hospital that is certified under Medicare as a short been excluded from the Inpatient Acute Care Hospital Prospective Payment System (IPPS) under §1886(d)(1)(B)(iv) of the Social Security Act. For the purpose of Medicare payment, LTCHs are defined as having an average inpatient length of stay (as determined by the Secretary) of greater than 25 days. • Code 99, other: if the resident was admitted from none of the above. Coding Tips and Special Populations , 07, Hospice • If an individual was enrolled in a home- based hospice program enter . 01, Community instead of A1900: Admission Date (Date this episode of care in this facility began) Item Rationale To document the date this episode of care in this facility began. • Coding Instructions • Enter the date this episode of care in this facility began . Use the format : Month- Day - 12, 2010, would be entered as 10-12-2010. For example, October -XXXX. Year : XX -XX • The Admission Date may be the same as the Entry Date (A1600) for the entire stay (i.e., if the resident is never discharged). -25 October 2018 Page A

143 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [A] A1900: Admission Date (Date this episode of care in this facility began) (cont.) Examples 1. on 09/14/2013 for Mrs. H was admitted to the facility from an acute care hospital rehabilitation after a hip replacement. In completing her Admission assessment , the facility enter ed 09/1 4/2013 in A1600, Entry Date ; code d A1700 = 1, Admission ; chose Code 03, acute hospital in item A1800, Entered ; and enter ed 09/1 4/2013 in item From A1900, Admission Date. 2. The facility received communication from an acute care hospital discharge planner stating that Mrs. H, a former resident of the facility who was discharged home return not anticipated on 11/02/2013 after a successful recovery and rehabilitation, was admitted to their hospital on 2/8/2014 and wished to return to the facility for rehabilitation after hospital discharge. Mrs. H returned to the facility on 2/15/2014. Although Mrs. H was a resident of the facility in September of 2013, she was discharged home return not anticipated ; therefore, the facility rightly considered Mrs. H as a new admission. In 02/15/2014 in A1600, Entry completing her Admission assessment, the facility entered Code 03, acute hospital in item A1800, hose coded A1700 = 1, Admission; c Date; ; and entered 02/15/2014 in item A1900, Admission Date. Entered From 3. Mr. K was admitted to the facility on 10/05/2013 and was discharged to the hospital, return anticipated, on 10/20/2013. He returned to the facility on 10/26/2013. Since Mr. K was a resident of the facility , was discharged return anticipated , and returned within 30 days of discharge, Mr. K was considered as continuing in his current stay. Therefore, when the facility completed his Entry Tracking Record on return from the hospital , they entered 1 0/26/2013 in A1600, Entry Date ; coded A1700 = 2, Reentry ; chose Code 03, acute hospital in item A1800; and entered 1 0/ 05/2013 in item A1900, Admission Date. Approximately a month after his return, Mr. K was again sent to the hospital, return anticipated on 11/05/2013. He returned to the facility on 11/22/2013. Again, since Mr. K , and returned within 30 , was discharged return anticipated was a resident of the facility discharge, Mr. K was considered as continuing in his current stay. Therefore, days of when the facility completed his Entry Tracking Record, they entered 11/22/2013 in ; coded A1700 = 2, Reentry ; chose Code 03, acute hospital in item A1600, Entry Date A1800; and e ntered 10/05/2013 in item A1900, Admission Date. 4. Ms. S was admitted to the facility on 8/26/2014 for rehabilitation after a total knee her s replacement. Three days after admission, Ms. S spiked a fever and urgical site was observed to have increased draina , swollen and extremely painful. The ge, was reddened facility sent Ms. S to the emergency room and completed her OBRA D isc harge assessment as return anticipated . T he hospital called the facility to inform them Ms. S admitted . A week into her hospitaliz ation, Ms. S developed a blood clot in her was affected leg, further complicating her recovery. The facility was contacted to readmit Ms. S for rehabilitative services following discharge from the hospital on 10/10/2014. Even though Ms. S was a former patient in the facility’s rehabilitation unit and was discharged -26 October 2018 Page A

144 CMS’s RAI Version 3.0 Manual CH MDS Items [A] 3: A1900: Admission Date (Date this episode of care in this facility began) (cont.) return anticipated, she did not return within 30 days of discharge to the hospital. Therefore, Ms. S is considered a new admission to the facility. On her return, when the facility completed Ms. S’s Admission assessment, they entered 10/10/2014 in A1600, Entry Date; coded A1700 = 1, Admission; chose Code 03, acute hospital in item A1800, Entered From; and entered 10/10/2014 in item A1900, Admission Date. Coding Tips and Special Populations • wing bed facilities and nursing homes must apply the above instructions for coding Both s e whether a patient or resident is an items A1600 through A1900 to determin admission/entry or reentry. In determining if a patient or resident returns to the facility within 30 days, the day of • For example, a resident discharge from the facility is not counted in the 30 days. discharged retur n anticipated on December 1 would need to return to the facility by December 31 to meet the “within 30 days ” requirement. If the Type of Entry for this assessment is an Admission (A1700 = 1), the Admission • Date (A1900) and the Entry Date (A1600) must be the same. If the Type of Entry for this assessment is a Reentry (A1700 = 2), the Admission Date • (A1900) will remain the same, and the Entry Date (A1600) must be later than the date in A1900. • Item A1900 (Admission Date) is tied to items A1600 (Entry Date), A1 700 (Type of Entry) , and A1800 (Entered From). It is also tied to the concepts of a “stay” and an “episode.” A stay is a set of contiguous days in the facility and an episode is a series of one or more stays that may be separated by brief interruptions in the resident’s time in the facility. An episode continues across stays until one of three events occurs: the resident is discharged with return not anticipated, the resident is discharged with return anticipated but is out of the facility for more than 30 days, or the resident dies in the facility. A1900 (Admission Date) should remain the same on all assessments for a given episode • even if it is interrupted by temporary discharges from the facility. If the resident is discharged and reenters within the cour episode, that will start a new stay. The se of an date in item A1600 (E ntry Date) will change, but the date in item A1900 (Admission Date) will remain the same. If the resident returns after a discharge return not anticipated or after a gap of more than 30 days outside of the facility, a new episode would begin and a new admission would be required. • When a resident is first admitted to a facility, item A1600 (Entry Date) should be coded with the date the person first entered the facility, and A1700 (Type of Entry) should be coded as 1, Admission. The place where the resident was admitted from should be documented in A1800 (Entered From), and the date in item A1900 (Admission Date) should match the date in A1600 (Entry Date). These items would be coded the sa me way If the resident is briefly for all subsequent assessments within the first stay of an episode. discharged (e.g., brief hospitalization) and then reenters the facility, a new (second) stay -27 October 2018 Page A

145 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A1900: Admission Date (Date this episode of care in this fac ility (cont.) began) would start, but the current episode would continue. On the Entry Tracking Record and on subsequent assessments for the second stay, the date in A1600 (Entry Date) would change depending on the date of reentry, and item A1700 (Type of Entry) would be coded as 2, Reentry. Item A1800 (Entered From) would reflect where the resident was prior to this reentry, and item A1900 (Admission Date) would continue to show the original admission date (the date that began his or her first stay in the episode). Discharge Date A2000: OBRA Item Rationale • Closes case in system. Coding Instructions Enter the date the resident was discharged (whether or not return is anticipated). This is • the date the resident leaves the facility. • For OBRA Discharge assessments, the Discharge D ate (A2000) and ARD (A2300) must be the same date. • Do not include leave of absence or hospital observational stay s less than 24 hours unless admitted to the hospital. Obtain data from the medical, admissions or transfer records. • Codi ng Tips and Special Populations • A Part A P PS Discharge assessment (NPE Item Set) is required under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) when the resident’s Medicare Part A stay ends, but the resident does not leave the facility. • If a resident receiving services under SNF Part A PPS has a Discharge Date (A2000) that the End Date of Most Recent Medicare Stay occurs on the day of or one day after (A2400C), then both an OBRA Discharge assessment and a Part A PPS Discharge assessment are required; but these two assessments may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000). -28 October 2018 Page A

146 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: Discharge Status A2100: OBRA Item Rationale ormation . • Demographic and outcome inf Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the 2 -digit code that corresponds to the resident’s discharge status. • Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility , or group home. • if discharge location is an Code 02, another nursing home or swing bed: titution (or a distinct part of an institution) that is primarily engaged in providing ins skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. wing beds. Includes s • Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. • Code 04, psychiatric hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill res idents. • if discharge location is an institution Code 05, inpatient rehabilitation facility: that is engaged in providing, under the supervision of physicians, rehabilitation services s that are units for the rehabilitation of injured, disabled or sick persons. Includes IRF within acute care hospitals . Code 06, ID/DD facility: if discharge location is an institution that is engaged in • providing, under the supervision of a physician, any health and rehabilitative services for individuals who have intellectual or developmental disabilities . • if discharge location is a program for terminally ill persons where Code 07, hospice: an array of services is necessary for the palliation and management of terminal illness and -29 October 2018 Page A

147 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A2100: OBRA Discharge Status (cont.) related conditions. The hospice must be licensed by the State as a hospice provider and/or certified under the Medicare program as a hospice provider . Includes community- based (e.g., home) or inpatient hospice programs. • Code 08, deceased: if resident is deceased. Code 09, long term care hospital (LTCH): • if discharge location is an institution that is certified under Medicare as a short -term, acute -care hospital which has been excluded from the Inpatient Acute Care Hospital Prospective Payment System (IPPS) under §1886(d)(1)(B)(iv) of the Social Security Act. For the purpose of Medicare (as determined payment, LTCHs are defined as having an average inpatient length of stay by the Secretary) of greater than 25 days. • if discharge location is none of the above. Code 99, other: A2200: Previous Assessment Reference Date for Significant Correction Item Rationale uarterly • To identify the ARD of a previous comprehensive (A0310 = 01, 03, or 04) or Q 02 ) in which a significant error is discovered. assessment (A03 10A = Instructions Coding Complete only if A0310A = 05 (Significant Correction to P • rior Comprehensive Assessment) or A0310A = 06 (Significant Correction to P rior Q uarterly A ssessment). which a significant Enter the ARD of the prior comprehensive or Q uarterly assessment in • error has been identified and a correction is required. A2300: Assessment Reference Date -30 October 2018 Page A

148 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [A] A2300: Assessment Reference Date (cont.) Item Rationale • Designates the end of the look- back period so that all assessment items refer to the ident’s status during the same period of time. res back period, the ARD serves as the reference point for As the last day of the look- . Anything that determining the care and services captured on the MDS assessment happens after the ARD will not be captured on that MDS . For example, for a MDS item with a 7 -day look-back period, assessment information is collected for a 7 -day period ending on and including the ARD which is the 7th day of this look-back period. For an mation is collected for a 14 -day period item with a 14 -day look- back period, the infor ending on and including the ARD. The look-back period includes observations and events through the end of the day (midnight) of the ARD. Steps for Assessment DEFINITION Interdisciplinary team members should select the ARD 1. ASSESSMENT based on the reason f or the assessment and compliance with REFERENCE DATE all timing and scheduling requirements outlined in (ARD) 2. Chapter The specific end -point for the Coding Instructions -back periods in the MDS look assessment process. Almost Enter the appropriate date on the lines provided. Do not • all MDS items refer to the If the month or day contains leave any spaces blank. resident’s status over a Use only a single digit, ente r a “0” in the first space. designated time period four digits for the year. , 2010, For example, October 2 referring back in time from should be entered as: 10-02-2010. the Assessment Reference For detailed information on the timing of the • Date (ARD). Most frequently, chedules . assessments, see Chapter 2 on a ssessment s this look -back period, also For discharge assessments, the discharge date item • called the observation or (A2000) and the ARD item (A2300) must contain the assessment period, is a 7- same date. day period ending on the ARD. Look -back periods may Coding Tips and Special Populations cover the 7 days ending on When the resident dies or is discharged prior to the end • this date, 14 days ending on of the look-back period for a required assessment, the this date, etc. ARD must be adjusted to equal the discharge date. • The look-back period may not be extended simply because a resident was out of the nursing home during part of the look-back period (e.g., a home visit, therapeutic leave, or hospital observation stay less than 24 hours when resident is not admitted ). For example, if the ARD is set at day 1 3 and there is a 2 -day temporary leave during the look- back period, the 2 leave days are still considered part of the look-back period. iod of the leave of When collecting assessment information, data from the time per • absence is captured as long as the particular MDS item permits . For example, if the family takes the resident to the physician during the leave, the visit would be counted in 0600, Physician Examination . Item O (if criteria are otherwise met) October 2018 -31 Page A

149 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [A] A2300: Assessment Reference Date (cont.) This requirement applies to all assessments, regardless of whether they are being completed for clinical or payment purposes. A2400: Medicare Stay Item Rationale • Identifies when a resident is receiving services under the scheduled PPS. • Identifies when a resident ’s Medicare Part A stay begins and ends. • The end date is used to determine if the resident ’s stay qualifies for the short stay assessment. Coding Instructions for A2400A , Has the DEFINITIONS Resident Had a Medicare -covered Stay RECENT MOST since the Most Recent Entry? STAY MEDICARE Code 0, no: • if th e resident has not had a Medicare This is a Medicare A Part Part A covered stay since the most recent that stay covered started has or reentry. Skip to B0100, Comatose. entry admission/ the recent most on or after or reentry to admission/entry Code 1, yes: if the resident has had a Medicare Part • nursing facility. the entry red stay since the most recent admission/ or A cove -COVERED MEDICARE reentry. Continue to A2400B. STAY Skilled Nursing Facility stays Coding Instructions for A2400B, Most Start of Part A. billable to Medicare Recent Medicare Stay include Does stays not billable to Medicare of this Medicare stay if • Code the date of day 1 HMO plans. Advantage A2400A is . coded 1, yes MEDICARE CURRENT Coding Instructions for A2400C, End Date of STAY ADMISSION: 1 of Day NEW Most Recent Medicare Stay stay. A Medicare Part of this Medicare stay if • Code the date of last day Day 1 of READMISSION: coded 1, yes A2400A is . Part Medicare A coverage a readmission following after discharge. -32 Page A October 2018

150 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A2400: Medicare Stay (cont.) If the Medicare Part A stay is ongoing , there will be no end date to report. Enter dashes to • ongoing. indicate that the stay is • The end of Medicare date is coded as follows, whichever occurs first: th Date SNF benefit exhausts (i.e., the 100 — day of the benefit); or Date of last day covered as recorded on the effective date from the Notice of — Medicare Non -Coverage (NOMNC) ; or — The last paid day of Medicare A when payer source changes to another payer (regardless if the resident was moved to another bed or not); or — Date the resident was discharged from the facility (see Item A2000, Discharge D ate). Coding Tips and Special Population s • When a resident on Medicare Part A returns following a therapeutic leave of absence or a hospital observation stay of less than 24 hours (without hospital admission) , this is a continuation of the Medicare Part A stay, not a new Medicare Part A stay. than earlier (A2400C) may be • the The E nd D ate of the Most Recent Medicare S tay actual Discharge Date (A2000) from the facility. If this occurs, the Part A PPS Discharge assessment is required. If the resident subsequently physically leaves the facility, the OBRA Discharge assessment would be required. • If the End Date of Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the Discharge Date (A2000), the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000) . tha occurs on the same day t • If the End Date of Most Recent Medicare Stay (A2400C) the resident dies, a Death in Facility Tracking Record is completed, with the Discharge Date (A2000) equal to the date the resident died. In this case, a Part A PPS Discharge not assessment is required. Part A PPS Discharge ass he End Date of the Most Recent standalone essment, t • For a 300). A2 D (Item Medicare Stay (A2400C) must be equal to the AR -33 October 2018 Page A

151 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A2400: Medicare Stay (cont.) Examples 1. Mrs. G. began receiving services under Medicare Part A on October 14, 2016. Due to her stable condition and ability to manage her medications and dressing changes, the facility determined that she no longer qualified for Part A SNF coverage and began planning her discharge. An Advanced Beneficiary Notice (ABN) and an NOMNC with the last day of ere issued. Mrs. G. was discharged home from the coverage as November 23, 2016 w facility on November 24, 2016. Code the following on her combined OBRA and Part A PPS Discharge assessment : A0310F = 10 • • A0310G = 1 • A0310H = 1 • A2000 = 11-24-2016 A2100 = 01 • • A2300 = 11-24-2016 A2400A = 1 • • A2400B = 10-14-2016 • A2400C = 11-23-2016 Rationale: Because Mrs. G’s last day covered under Medicare was one day before her physical discharge from the facility, a combined OBRA and Part A PPS Discharge was completed. Mr. N began receiving services under Medicare Part A on December 11, 2016. He was 2. unexpectedly sent to the ER on December 19, 2016 at 8:30pm and was not admitted to the hospital. He returned to the facility on December 20, 2016, at 11:00 am. The facility an ARD of December 23, 2016. Code the day PPS assessment with completed his 14- following on his 14- day PPS assessment: • A2400A = 1 • A2400B = 12-11-2016 A2400C = ---------- • Rationale: Mr. N was out of the facility at midnight but returned in less than 24 hours and was not admitted to the hospital, so was considered LOA. Therefore, no Discharge assessment was required. His Medicare Part A Stay is considered ongoing; therefore, the date in A2400C is dashed. -34 October 2018 Page A

152 CMS’s RAI Version 3.0 Manual MDS Items [A] CH 3: A2400: Medicare Stay (cont.) 3. Mr. R. began receiving services under Medicare Part A on October 15, 2016. Due to complications from his recent surgery, he was unexpectedly discharged to the hospital for emergency surgery on October 20, 2016, but is expected to return within 30 days. Code the following on his OBRA Discharge assessment: • A0310F = 11 A0310G = 2 • • A0310H = 1 A2000 = 10-20-2016 • • A2100 = 03 • A2300 = 10-20-2016 • A2400A = 1 • A2400B = 10-15-2016 A2400C = 10-20-2016 • Rationale: Mr. R’s physical discharge to the hospital was unplanned, yet it is anticipated that he will return to the facility within 30 days. Therefore, only an OBRA Discharge was required. Even though only an OBRA Discharge was required, when the Date of the End of the Medicare Stay is on the day of or one day before the Date of Discharge, MDS specifications require that A0310H be coded as 1. 4. Mrs. K began receiving services under Medicare Part A on October 4, 2016 . She was discharged from Medicare Part A services on December 17, 2016. She and her family had already decided that Mrs. K would remain in the facility for long -term care services, and she was moved into a private room (which was dually certified) on December 18, 2016. Code the following on her Part A PPS Discharge assessment: • A0310F = 99 • A0310G = ^ • A0310H = 1 A2000 = ^ • A2100 = ^ • • A2300 = 12-17-2016 • A2400A = 1 • A2400B = 10-04-2016 • A2400C = 12-17-2016 Rationale: Because Mrs. K’s Medicare Part A stay ended, and she remained in the standalone Part A PPS Discharge was required. facility for long -term care services, a -35 October 2018 Page A

153 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH A2400: Medicare Stay (cont.) 15, 2016. His began receiving services under Medicare Part A on November 5. Mr. W Medicare Part A stay ended on November 25, 2016, and he was unexpectedly discharged to the hospital on November 26, 2016. However, he is expected to return to the facility within 30 days . Code the following on his OBRA Discharge assessment: • A0310F = 11 A0310G = 2 • A0310H = 1 • • A2000 = 11-26-2016 • A2100 = 03 • A2300 = 11-26-2016 • A2400A = 1 • A2400B = 11-15-2016 • A2400C = 11-25-2016 Mr. W’s Medicare stay ended the day before discharge and he is expected to Rationale: return to the facility within 30 days. Because his discharge to the hospital was unplanned, only an OBRA Discharge assessment was required. Even though only an OBRA y is on the day of Discharge was required, when the Date of the End of the Medicare Sta or one day before the Date of Discharge, MDS specifications require that A0310H be . coded as 1 -36 October 2018 Page A

154 CMS’s RAI Version 3.0 Manual 3: MDS Items [A] CH Medicare Stay End Date Algorithm A2400C Is the resident's Medicare stay Enter dashes Yes ongoing? No Did the resident's Enter the date of the Yes SNF benefit last covered day, exhaust? i.e., the 100th day No Enter the effective Was a generic date on the Generic notice issued to the Yes Notice for last resident? covered day* No Did the resident's Enter the date of the payer source last paid day of Yes change from Part A Medicare A to another payer? No Enter the date resident was discharged from facility *if resident leaves facility prior to last covered day as recorded on the generic . notice, enter date resident left facility October 2018 Page A -37

155 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] SECTION B: HEARING, SPEECH, AND VISION The intent of items in this section is to document the resident’s ability to hear (with Intent: assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. B0100: Comatose DEFINITION Item Rationale (coma) COMATOSE Health Quality of Life -related A pathological state in which Residents who are in a coma or persistent vegetative • arousal (wakefulness, neither of immobility, complications state are at risk for the alertness) nor awareness including skin breakdown and joint contractures. is exists. The person and cannot unresponsive be Planning for Care not he/she does aroused; not eyes, does his/her open • Care planning should center on eliminating or move and speak does not care consistent providing and minimizing complications on his/her extremities with the resident’s health care goals. response or in to command pain). (e.g., noxious stimuli Steps for Assessment 1. Review the medical record to determine if a neurological diagnosis of comatose or persistent vegetative state has been documented by a physici an, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. Coding Instructions if a diagnosis of coma or persistent vegetative state is not present during • Code 0, no : . Hearing the 7-day look-back period. Continue to B0200 • if the record indicates that a physician , nurse practitioner or clinical nurse : Code 1, yes vegetative state that is specialist has documented a diagnosis of coma or persistent applicable during the 7- day look- back period . Skip to Section G0110, Activities of Daily Living (ADL) Assistance . B-1 Page October 2018

156 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B0100: Comatose (cont.) DEFINITION Coding Tips PERSISTENT • Only code if a diagnosis of coma or persistent VEGETATIVE STATE . For example, some vegetative state has been assigned who Sometimes residents residents in advanced stages of progressive neurologic an were after comatose disorders such as Alzheimer ’s disease may have severe injury (i.e., anoxic -ischemic to the enough oxygen not communicative and sleep cognitive impairment, be non- from brain) a cardiac a great deal of time; however, they are usually not head trauma, arrest, or , as defined comatose or in a persistent vegetative state massive stroke, regain here. but wakefulness do not evidence any purposeful or cognition. Their behavior eyes open, are and they may pick grunt, yawn, with their have random fingers, and movements. body exam Neurological shows extensive damage to both hemispheres. cerebral B0200: Hearing Item Rational e Health -related Quality of Life • Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. • Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Planning for Care • Address r eversible causes of hearing difficulty (such as cerumen impaction). • Evaluate potential benefit from hearing assistance devices. • Offer assistance to r esidents with hearing difficulties to avoid social isolation. Page October 2018 B-2

157 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B0200: Hearing (cont.) • Consider other communication strategies for persons with hearing loss that is not corrected with hearing devices. reversible or is not completely • Adjust environment by reducing background noise by lowering the sound volume on televisions or radios, because a noisy environment can inhibit opportunities for effective communication . Steps for Assessment 1. Ensure that the resident is using his or her normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. 2. Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using telephone, watching TV, attending activities). 3. Observe the resident during your verbal interactions and when he or she interacts with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone, speak more slowly or use gestures. The resident may need to see your face to understand what you are saying, or you may need to take the resident to a quieter area for them to hear you. All of these are cues that there is a hearing problem. the medical record. Review 5. Consult the resident’s family, direct care staff, activities personnel, and speech or hearing 6. specialists. Coding Instructions Code 0, adequate: • No difficulty in normal conversation, social interaction, or listening to TV . The resident hears all normal conversational speech and telephone conversation and announcements in group activities. Code 1, • Difficulty in some environments (e.g., when a person : minimal difficulty . The resident hears speech at conversational levels speaks softly or the setting is noisy) but has difficulty hearing when not in quiet listening conditions or when not in one-on- one situations. The resident’s hearing is adequate after environmental adjustments are made, such as reducing background noise by moving to a quiet room or by lowering the volume on television or radio. : difficulty moderate Code 2, Speaker has to increase volume and speak distinctly. • -deficient, the resident compensates when the speaker adjusts tonal Although hearing quality and speaks distinctly; or the resident can hear only when the speaker’s face is clearly visible. Page October 2018 B-3

158 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B0200: Hearing (cont.) • Code 3, h ighly impaired: Absence of useful hearing . The resident hears only some sounds and frequently fails to respond even when the speaker adjusts tonal quality, speaks distinctly, or is positioned face- to-face. There is no comprehension of conversational speech, even when the speaker makes maximum adj ustments. Coding Tips for Special Populations • Residents who are unable to respond to a standard hearing assessment due to cognitive impairment will require alternate assessment methods. The resident can be observed in their normal environment. Does he or she respond (e.g., turn his or her head) when a noise is made at a normal level? Does the resident seem to respond only to specific noise in a quiet environment? Assess whether the resident responds only to loud noise or do they not respond at all. B0300: Hearing Aid Item Rationale Health -related Quality of Life • Problems with hearing can contribute to social isolation and mood and behavior disorders. impaired hearing could benefit from hearing aids or other hearing Many residents with • appliances . • Many res idents who own hearing aids do not have the hearing aids with them or have nonfunctioning hearing aids upon arrival. Planning for Care • Knowing if a hearing aid was used when determining hearing ability allows better identification of evaluation and management needs. • For residents with hearing aids, use and maintenance should be included in care planning. • Residents who do not have adequate hearing without a hearing aid should be asked about history of hearing aid use. Residents who do not have adequate hearing despite wearing a hearing aid might benefit • from a re -evaluation of the device or assessment for new causes of hearing impairment. Steps for Assessment 1. Prior to beginning the hearing assessment, ask the resident if he or she ow ns a hearing aid or other hearing appliance and, if so, whether it is at the nursing home. If the resident cannot respond, write the question down and allow the resident to read it. 2. Page October 2018 B-4

159 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B0300: Hearing Aid (cont.) 3. If the resident is still unable, check with family and care staff about hearing aid or other hearing appliances. 4. Check the medical record for evidence that the resident had a hearing appliance in place when hearing ability was recorded. and significant others whether the resident was using a hearing appliance when they 5. Ask staff observed hearing ability (above). Coding Instructions • Code 0, no : if the resident did not use a hearing aid (or other hearing appliance) for the coded in 7-day hearing assessment B0200, Hearing . • Code 1, y es: if the resident did use a hearing aid (or other hearing appliance) for the . B0200, Hearing hearing assessment coded in B0600: Speech Clarity Item Rationale DEFINITION -related Quality of Life Health SPEECH The verbal expression of Unclear speech or absent speech can hinder • articulate words. communication and be very frustrating to an individual. • Unclear speech or absent speech can result in physical and psychosocial needs not being met and can contribute to depression and social isolation. Planning for Care If speech is absent or is not clear enough for the resident to make needs known, other • methods of communication should be explored. Lack of speech clarity or ability to speak should not be mistaken for cognitive • impairment. Steps for Assessment Listen to the residen t. 1. primary assigned caregivers about the resident’s speech pattern. Ask 2. the medical record. Review 3. Page October 2018 B-5

160 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B0600: Speech Clarity (cont.) Determine the quality of the resident’s speech, not the content or appropriateness—just 4. words spoken. Coding Instructions clear speech: • if the resident usually utters distinct, intelligible words . Code 0, • Code 1, u nclear speech: if the resident usually utters slurred or mumbled words. • Code 2, n o speech: if there is an absence of spoken words. B0700: Makes Self Understood Item Rationale DEFINITION Quality of Life Health -related MAKES SELF UNDERSTOOD Problems making self understood can be very • to express Able or frustrating for the resident and can contribute to social communicate requests, isolation and mood and behavior disorders. and to opinions, needs, Unaddressed communication problems can be • conduct social conversation inappropriately mistaken for confusion or cognitive in his or her primary impairment. speech, language, whether in writing, sign language, Planning for Care gestures, or a combination of ability in the these. Deficits to • Ability to make self understood can be optimized by not make one’s self understood rushing the resident, breaking longer questions into (expressive communication parts and waiting for reply, and maintaining eye contact reduced include deficits) can (if appropriate). in and voice volume difficulty producing sounds, or • making self understood: If a resident has difficulty in finding right the difficulty — Identify the underlying cause or causes. word, making sentences, gesturing. and/or writing, — Identify the best methods to facilitate communication for that resident. Page B-6 October 2018

161 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] (cont.) B0700: Makes Self Understood Steps for Assessment Assess using the resident’s preferred language 1. of communication . or method 2. Interact with the resident. Be sure he or she can hear you or have access to his or her preferred method for communication. If the resident seem s unable to communicate, offer alternatives such as writing, pointing , or using cue cards. , sign language 3. Observe his or her interactions with others in different settings and circumstances . 4. Consult with the primary nurse assistant s (over all shifts) and the resident’s family a nd speech -language pathologist. Coding Instructions he resident expresses requests and ideas clearly. if t : • Code 0, u nderstood he resident has difficulty communicating some • sually understood: if t Code 1, u words or finishing thoughts but is able if prompted or given time . He or she may have delayed responses or may require some prompting to make self understood. • Code 2, s ometimes understood: if t he resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet). • , the resident’s understanding is t best Code 3, rarely or n ever understood: if, a limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet). Coding Tips and Special Populations • This item cannot be coded as Rar ely/Never Understood if the resident completed any of the resident interviews, as the interviews are conducted during the look-back period for this item and should be factored in when determining the residents’ ability to make self understood during the entire 7 -day look-back period. • While B0700 and the resident interview items are not directly dependent upon one another, inconsistencies in coding among these items should be evaluated. B0800: Ability to Understand Others Page October 2018 B-7

162 CMS’s RAI Version 3.0 Manual MDS Items [B] CH 3: B0800: Ability to Understand Others (cont.) Item Rationale Health -related Quality of Life • Inability to understand direct person- to-person communication — Can severely limit association with others . — Can inhibit the individual’s ability to follow instructions that can affect health and safety . Planning for Care DEFINITION • Thorough assessment to determine underlying cause or causes is critical in order to develop a care plan to TO ABILITY address the individual’s specific deficits and needs. UNDERSTAND OTHERS of direct Comprehension • Every effort should be made by the facility to provide person- to-person information to the resident in a consistent manner that communication whether he or she understands based on an individualized spoken, written, or in sign assessment. or Braille. Includes language resident’s ability the to Steps for Assessment process and understand in one’s Deficits language. Assess in the resident’s preferred language 1. or preferred ability to understand method of communication . (receptive communication 2. If the resident uses a hearing aid, hearing device or other involve declines deficits) can communications enhancement device, the resident should comprehension in hearing, use that device during the evaluation of the resident’s (spoken or written) or of facial recognition understanding of person- to-person communication. expressions. 3. Interact with the resident and observe his or her understanding of other’s communication. 4. Consult with direct care staff over all shifts , if possible, the resident’s family, and speech - language path ologist (if involved in care). 5. Review the medical record for indications of how well the resident understands others. Coding Instructions : • Code 0, u nderstands if t he resident clearly comprehends the message(s) and demonstrates comprehension by words or actions/behaviors. es some part or intent of the • Code 1, u sually understands : if t he resident miss but comprehends most of it. The resident may have periodic difficulties message integrating information but generally demonstrates comprehension by responding in words or actions. • ometimes Code 2, s if the resident demonstrates frequent difficulties : understands uately only to simple and direct questions or integrating information, and responds adeq B-8 Page October 2018

163 CMS’s RAI Version 3.0 Manual MDS Items [B] CH 3: B0800: Ability to Understand Others (cont.) instructions. When staff rephrase or simplif y the message(s) and/or use gestures, the resident’s comprehension is enhanced. • Code 3, rarely/ never understands : if t he resident demonstrates very limited ability to understand communication. Or, if staff ha ve difficulty determining whether or comprehends messages, based on verbal and nonverbal responses. Or, the not the resident resident can hear sounds but does not unders tand messages. B1000: Vision Item Rationale DEFINITION Health -related Quality of Life ADEQUATE LIGHT Lighting that is sufficient or • A person’s reading vision often diminishes over time. comfortable for a person with If uncorrected, vision impairment can limit the • normal vision to see fine enjoyment of everyday activities such as reading detail. newspapers, books or correspondence, and maintaining and enjoying hobbies and other activities. It also limits the ability to manage personal business, such as reading and signing consent forms. • Moderate, high or severe impairment can contribute to sensory deprivation, social , and depressed mood. isolation Planning for Care Reversible causes of vision impairment should be sought. • • Consider whether simple environment al changes such as better lighting or magnifiers would improve ability to see. Consider large print reading materials for persons with impaired vision. • • For residents with moderate, high, or severe impairment, consider alternative ways of providing access to content of desired reading materials or hobbies. Steps for Assessment Ask direct care staff over all shifts if possible about the resident’s usual vision patterns 1. -day look-back period (e.g., is the resident able to see newsprint, menus, gree during the 7 ting cards ?). Then ask the resident about his or her visual abilities. 2. Test the accuracy of your findings: 3. B-9 Page October 2018

164 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B1000: Vision (cont.) • Ensure that the resident’s customary visual appliance for close vision is in place (e.g., es, magnifying glass). eyeglass • Ensure adequate lighting. • Ask the resident to look at regular-size print in a book or newspaper. Then ask the resident to read aloud, starting with larger headlines and ending with the finest, smallest print. If the resident is unable to read a newspaper, provide material with larger print, such as a flyer or large textbook. • When the resident is unable to read out loud (e.g. due to aphasia, illiteracy), you should test this by another means such as, but not limited to: — Substituting numbers or pictures for words that are displayed in the appropriate print size (regular -size print in a book or newspaper). Coding Instructions • Code 0, a dequate: if t he resident sees fine detail, including regular print in newspapers/books. print, but not regular print in arge e resident sees l if th impaired: • Code 1, newspapers/books. • is not able to Code 2, moderately impaired: if t he resident has limited vision and see newspaper headlines but can identify objects in his or her environment. • Code 3, h ighly impaired: if t he resident’s ability to identify objects in his or her environment is in question, but the resident’s eye movements appear to be following objects (especially people walking by). Code 4, s • he resident has no vision, sees only light, colors or if t everely impaired: shapes, or does not appear to follow objects with eyes . Coding Tips and Special Populations • Some residents have never learned to read or are unable to read English. In such cases, ask the resident to read numbers, such as dates or page numbers, or to name items in small pictures . Be sure to display this information in two sizes (equivalent to regular and large print). • If the resident is unable to communicate or follow your directions for testing vision, observe the resident’s eye movements to see if his or her eyes seem to follow movement These gross measures of visual acuity may assist you in assessing of objects or people. whether or not the resident has any visual ability. For residents who appear to do this, code 3, highly impaired . B- 10 October 2018 Page

165 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B1200: Corrective Lenses Item Rationale Health -related Quality of Life • Decreased ability to see can limit the enjoyment of everyday activities and can contribute to social isolation and mood and behavior disorders. • Many residents who do not have corrective lenses could benefit from them, and others have corrective lenses that are not sufficient. • Many persons who benefit from and own visual aids do not have them on arrival at the nursing home. Planning for Care • Knowing if corrective lenses were used when determining ability to see allows better identification of evaluation and management needs. es or other visual appliances should be assisted in accessing them. Residents with eyeglass • Use and maintenance should be included in care planning. es or other visual appliances Residents who do not have adequate vision without eyeglass • should be asked about history of corrective lens use. Residents who do not have adequate vision, despite using a visual appliance, might • benefit from a re -evaluation of the appliance or assessmen t for new causes of vision impairment. Steps for Assessment 1. Prior to beginning the assessment, ask the resident whether he or she uses eyeglasses or other vision aids and whether the eyeglasses or vision aids are at the nursing home. Visual aids do not include surgical lens implants. 2. cannot respond, check with family and care staff about the resident’s use of If the resident back period . vision aids during the 7-day look- glasses or other vision aids during reading vision test 3. Observe whether the resident used eye (B1000). 4. Check the medical record for evidence that the resident used corrective lenses when ability to see was recorded. 5. aff and significant others whether the resident was using corrective lenses when they Ask st observed the r esident’s ability to see. B- 11 October 2018 Page

166 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [B] B1200: Corrective Lenses (cont.) Coding Instructions Code glasses or other vision aid during the if the resident did not use eye no : 0, • assessment. B1000, Vision • or other visual aids were used when visual ability was Code 1, yes: if corrective lenses B1000, Vision assessed in completing . B- 12 October 2018 Page

167 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] SECTION C: COGNITIVE PATTERNS Intent: items in this section are intended to determine the resident’s attention, orientation The These items are crucial factors in many care - and ability to register and recall new information. planning decisions. C0100: Should Brief Interview for Mental Status Be Conducted? Item Rationale Health -related Quality of Life • Most residents are able to attempt the Brief Interview for Mental Status (BIMS). • A str uctured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. — Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. — Struct ured interviews will efficiently provide insight into the resident’s current condition that will enhance good care. Planning for Care • Structured cognitive interviews assist in identifying needed supports. ossible delirium behaviors dentifying p The structured cognitive interview is helpful for i • (C1310). Steps for Assessment 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine if the resident is rarely/never understood verbally , in writing , or using another method . If rarely/never understood, skip to C0700–C1000, Staff Assessment of Mental . Status 3. Language item (A1100), to determine if the resident needs or wants an interpreter. Review If the resident needs or wants an interpreter, complete the interview with an interpreter. • Coding Instructions • o: Code 0, n if the interv iew should not be conducted because the resident is or in writing rarely/never understood ; cannot respond verbally , , or using another method; an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status. Page October 2018 C-1

168 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0100: Should Brief Interview for Mental Status Be Conducted? (cont.) • Code 1, y es: if the interview should be conducted because the resident is at least sometimes understood verbally , in writing , or using another method , and if an interpreter is needed, one is available. Proceed to C 0200, Repetition of Three Words. Coding Tips • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. • If the resident needs an interpreter, every effort should be made to have an interpreter present for the BIMS. If it is not possible for a needed interpreter to participate on the day of the interview, code C 0100 = 0 to indicate interview not attempted and complete Staff Assessment of Mental Status C0700-C1000, Brief , instead of C0200-C0500, Interview for Mental Status . • Includes residents who use American Sign Language (ASL). • If the resident interview was not conducted within the look- back perio d (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard “no information” code (a dash “- ”) entered in the resident interview items. • Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done. • There is one exception to completing the Staff Assessment for Mental Status items (C0700–C1000) in place of the resident interview. This exception is specific to a stand- alone, unscheduled PPS assessment only and is discussed on page 2-60. For this type of assessment only, the resident interview may be conducted up to two calendar days after the ARD. When coding a stand-alone Change of Therapy OMRA • (COT), a stand-alone End of Therapy OMRA (EOT), or a stand-alone Start of Therapy OMRA (SOT), the interview items may be coded using the responses provided by the resident on a previous of the interview responses from the previous assessment (as assessment only if the DATE of documented in item Z0400) were obtained no more than 14 days prior to the DATE completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used. Page October 2018 C-2

169 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0200-C0500: Brief Interview for Mental Status (BIMS) C-3 Page October 2018

170 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.) Item Rationale Health -related Quality of Life • -based testing of cognitive function decreases the chance of Direct or performance incorrect labeling of cognitive ability and improves detection of delirium. • Cognitively intact residents may appear to be cognitively impaired because of extreme frailty, hearing impairment or lack of interaction. • Some residents may appear to be more cognitively intact than they actually are. • When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile activities and therapies may not be offered. A resident’s performance on cognitive tests can be compared over time. • — If performance worsens, then an assessment for delirium and or depression should be considered. • The BIMS is an opportunity to observe residents for signs and s ymptoms of delirium (C1310). Planning for Care Assessment of a resident’s mental state provides a direct understanding of resident • function that may: enhance future communication and assistance and — — direct nursing interventions to facilitate greater independence such as posting or providing reminders for self -care activities. • A resident’s performance on cognitive tests can be compared over time. — An abrupt change in cognitive status may indicate delirium and may be the only indication of a potentially life threatening illness. — A decline in mental status may also be associated with a mood dis order. • Awareness of possible impairment may be important for maintaining a safe environment and providing safe discharge planning. Steps for Assessment - : Basic Interview Instructions for BIMS (C0200 C0500) 1. Refer to Appendix D for a review of basic approache s to effective interviewing techniques. 2. Interview any resident not screened out by Should Brief Interview for Mental Status Be Conducted? (Item C0100). 3. Conduct the interview in a private setting. 4. Be sure the resident can hear you. • Residents with hearing impairment should be tested using their usual communication devices/techniques, as applicable. Page October 2018 C-4

171 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.) • Try an external assistive device (headphones or hearing amplifier ) if you have any doubt about hearing ability. Minimize background noise. • 5. Minimize glare by directing light sources away Sit so that the resident can see your face. from the resident’s face. Give an introduction before starting the interview. 6. Suggested language : “I would like to ask you some questions. We ask everyone these same questions. This will help us provide you with better care. Some of the questions may seem very easy, while others may be more difficult.” 7. If the resident expresses concern that you are testing his or her memory, he or she may be “We ask these questions of everyone so we can make sure more comfortable if you reply: that our care will meet your needs.” 8. Directly ask the resident each item in C0200 through C0400 at one sitting and in the order provided. 9. If the resident chooses not to answer a particular item, accept his or her refusal and move on to the next questions. For C0200 through C0400, code refusals as incorrect. Coding Instructions See coding instructions for individual items. Coding Tips • On occasion, the int erviewer may not be able to state the items clearly because of an cognitive items . If the interviewer is unable to pronounce any or slurred speech accent clearly, have a different staff member complete the BIMS . Nonsensical responses should be coded as ze ro. • Rules for stopping the i nterview before it is complete: • — Stop the interview after completing (C 0300C ) “ Day of the Week ” if : 1. all responses have been nonsensical (i.e., any response that is unrelated, incomprehensible, or incoherent; not informative with respect to the item being rated ), OR 2. there has been no verbal or written response to any of the questions up to this point, OR 3. there has been no verbal or written response to some questions up to this point and for all others, the resident has given a nonsensical response. • If the interview is stopped, do the following: -, dash in C0400A, C0400B, and C0400C. 1. Code 2. Code 99 in the summary score in C0500. 3. Code 1, yes in C0600 Should the Staff Assessment for Mental Status (C0700- C1000) be Conducted? Complete the . Staff Assessment for Mental Status 4. Page October 2018 C-5

172 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.) • When staff identify that the resident’s primary method DEFINITION of communication is in written format, the BIMS can be The administration of the administered in writing. NONSENSICAL BIMS in writing should be limited to this RESPONSE circumstance. Any is that response • See Appendix E for details regarding how to administer unrelated, the BIMS in writing. incomprehensible, or incoherent; it is not Examples of Incorrect and Nonsensical informative with to respect being item the rated. Responses . This answer is . The resident replies that it is 1935 nterviewer asks resident to state the year 1. I t but related to the question. incorrec This a nswer is coded 0, incorrect but would NOT be considered a Coding: nonsensical response . The answer is wrong, but it is logical and relates to the question. Rationale: . The resident says, “Oh what difference does the nterviewer asks resident to state the year I 2. make when you’re as old as I am?” The interviewer asks the resident to try to name the year year, and the resident shrugs. This answer is coded 0, incorrect but would NOT be considered a Coding: nonsensical response . The answer is wrong because refusal is considered a wrong answer, but the Rationale: resident’s comment is logical and clearly relates to the question. esident answers, “Sylvia, she’s name the day of the week. R Interviewer asks the resident to 3. my daughter.” coded 0, incorrect The answer is Coding: ; the response is illogical and nonsensical. and the resident’s comment clearly does not relate to Rationale: The answer is wrong, the question; it is nonsensical. C0200: Repetition of Three Words C-6 Page October 2018

173 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0200: Repetition of Three Words (cont.) Item Rationale -related Quality of Life Health • Inability to repeat three words on first attempt may indicate: — a hearing impairment, — a language barrier, or inattention that may be a sign of delirium. — Planning for Care • A cue can assist learning. • Cues may help residents with memory impairment who can store new information in their memory but who have trouble retrieving something that was stored (e.g., not able to remember someone’s name but can recall if given part of the first name). Staff can use cues when assisting residents with learning and recall in therapy, and in • daily and restorative activities. Steps for Assessment DEFINITION -3 and Basic BIMS interview instructions are shown on page s C CUE CATEGORY C-4. In addition, for repetition of three words: Phrase puts a word in that Say to the resident: “I am going to say three words for you 1. with learning to help context to remember. Please repeat the words after I have said all and to serve as a hint that Interviewers three. The words are: sock, blue, and bed.” prompt helps the resident. need to use the words and related category cues as The is category cue for sock indicated. If the interview is being conducted with an to wear.” “something The blue is “a cue for category interpreter present, the interpreter should use the equivalent color.” For bed, the category words and similar, relevant prompts for category cues. of furniture.” is “a piece cue Immediately after presenting the three words, say to the 2. resident : “Now please tell me the three words.” 3. After the resident’s first attempt to repeat the items: , “That’s right, the words are sock, • If the resident correctly stated all three words, say something to wear; blue, a color; and bed, a piece of furniture” [category cues]. Category cues serve as a hint that helps prompt residents’ recall ability . Putting words in • context stimulates learning and fosters memory of the words that residents will be asked to recall in ite m C0400, even among residents able to repeat the words immediately. If the resident recalled two or fewer words, say to the resident: “Let me say the three • words again. They are sock, something to wear; blue, a color; and bed, a piece of furniture. Now te ll me the three words.” If the resident still does not recall all three words . correctly, you may repeat the words and category cues one more time C-7 Page October 2018

174 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0200: Repetition of Three Words (cont.) If the resident does not repeat all three words after three attempts, re -assess ability to • hear . If the resident can hear, move on to the next question. If he or she is unable to hear, attempt to maximize hearing (alter environment, use hearing amplifier) before proceeding. Coding Instructions Record the maximum number of words that the resident correctly repeated on the first attempt. This will be any number between 0 and 3. • The words may be recalled in any order and in any context. For example, if the words are repeated back in a sentence, they would be counted as repeating the words. • Do not score the number of repeated words on the second or third attempt. These attempts help with learning the item, but only the number correct on the first attempt go attempts that the resident needed to into the total score. Do not record the number of complete. • one: if the resident did not repeat any of the 3 words on the first attempt. Code 0, n Code 1, o ne: if the resident repeated only 1 of the 3 words on the first attempt. • • Code 2, two: if the resident repeated only 2 of the 3 words on the first attempt. l 3 words on the first attempt. if the resident repeated al • Code 3, three: Coding Tips On occasion, the interviewer may not be able to state the words clearly because of an • or slurred speech. If the interviewer is unable t o pronounce any of the 3 words accent clearly, have a different staff member conduct the interview. Examples 1. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three words.” The resident replies, “B ed, sock, and blue.” The interviewer repeats the three words with category cues, by saying, “That’s right, the words are sock, something to wear; blue , a color; and bed, a piece of furniture.” words correct. Coding: C0200 would be coded 3, three The resident repeated all three items on the first attempt. The order of Rationale: repetition does not affect the score. 2. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three ock, bed, black.” The int words.” The resident replies, “S erviewer repeats the three words plus the category cues, saying, “ , something Let me say the three words again. They are sock to wear; blue, a color; and bed, a piece of furniture. Now tell me the three words.” The resident says , “Oh yes, that’s right, sock, blue, bed.” Coding: C0200 would be coded 2, two of three words correct. Residents The resident repeated two of the three items on the first attempt. Rationale: are scored based on the first attempt. Page October 2018 C-8

175 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] (cont.) C0200: Repetition of Three Words The interviewer says, “The words are sock, blue, and bed. Now please tell me the three 3. words.” The resident says, “Blue socks belong in the dresser.” The interviewer repeats the three words plus the category cues. C0200 would be coded 2, two of the three words correct. Coding: The resident repeated two of the three items Rationale: The resident —blue and sock. of the three words. put the words into a sentence, resulting in the resident repeating two 4. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three words.” The resident replies, “What were those three words?” The interviewer repeats the three words plus the category cues. Coding: C0200 would be coded 0, none of the words correct. Rationale: The resident did not repeat any of the three words after the first time the interviewer said them . C0300: Temporal Orientation (Orientation to Year, Month, and Day) DEFINITION Item Rationale TEMPORAL Health -related Quality of Life ORIENTATION A lack of temporal orientation may lead to decreased • the to place ability In general, communication or participation in activities. oneself For in correct time. the to BIMS, it is the ability • Not being oriented may be frustrating or frightening. the correct date in indicate Planning for Care current surroundings. , they can provide If staff • know that a resident has a problem with orientation . reorientation aids and verbal reminders that may reduce anxiety Page October 2018 C-9

176 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0300: Temporal Orientation (Orientation to Year, Month, and Day) (cont.) Reorienting those who are disoriented or at risk of disorientation may be useful in • treating symptoms of delirium. • Residents who are not oriented may need further assessment for delirium, especially if this fluctuates or is recent in onset. Steps for Assessment Basic BIMS interview instructions are shown on pages C-3 and C-4. 1. Ask the resident each of the 3 questions in I tem C 0300 separately . 2. Allow the resident up to 30 seconds for each answer and do not provide clues. 3. If the resident specifically asks for clues (e.g., “is it bingo day?”) respond by saying, “I need to know if you can answer this question without any help from me.” Coding Instructions for C0300A , Able to Report Correct Year • Code 0, missed by >5 years or no answer: if the resident’s answer is incorrect and is greater than 5 years from the current year or the resident chooses not to answer the item. • Code 1, missed by 2 -5 years : if the resident’s answer is incorrect and is within 2 to 5 years from the current year. • missed by 1 year: Code 2, within one is if the resident’s answer is incorrect and year from the current year. Code 3, c orrect: • . if the resident states the correct year Examples 1. The date of interview is May 5, 2011. The resident, responding to the statement, “Please tell me what year it is right now,” states that it is 20 11. Coding: C0300A would be coded 3, correct . 2011 is the current year. Rationale: is June 16, 2011. The resident, responding to the statement, “Please tell The date of interview 2. 07. me what year it is right now,” states that it is 20 Coding: C0300A would be coded 1, missed by 2- 5 years . Rationale: 2007 is within 2 to 5 years of 2011. 3. The date of interview is January 10, 2011. The resident, responding to the statement, “Please tell me what year it is right now,” states that it is 19 11. C0300A would be . coded 0, missed by more than 5 years Coding: part of the year would be correct, 1911 is more than 5 Even though the ’11 Rationale: years from 2011. 10 October 2018 Page C-

177 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C0300: Temporal Orientation (Orientation to Year, Month, and Day) (cont.) 4. The date of interview is April 1, 2011. The resident, responding to the statement, “Please tell me what year it is right now,” states that it is “’11”. The interviewer asks, “Can you tell me the full year?” The resident still responds “ ’11 ,” and the interviewer asks again, “C an you tell -two.” The resident states -eighty me the full year, for example, nineteen , “2011.” C0300A would be coded 3, correct . Coding: Rationale: Even though ’11 is partially correct, the only correct answer is the exact 11,” not “’11” or year. The resident must state “20 “1811” or “1911.” Coding Instructions for C0300B, Able to Report Correct Month Count the current day as day 1 w hen determining whether the response was accurate within 5 days or missed by 6 days to 1 month. missed by >1 month or no answer: if the resident’s answer is incorrect • Code 0, by more than 1 month or if the resident chooses not to answer the item. • Code 1, if the resident’s answer is accurate within missed by 6 days to 1 month: 6 days to 1 month. • Code 2, a ccurate within 5 days: if the resident’s answer is accurate within 5 days, count current date as day 1. Coding Tips • In most instances, it will be immediately obvious which code to select. In some cases, you may need to write the resident’s response in the margin and go back later to count days if you are unsure whether the date given is within 5 days. Examples nt, responding to the question, “What is June 25, 2011. The reside The date of interview 1. month are we in right now?” states that it is June. Coding: C0300B would be coded 2, accurate within 5 days . Rationale: resident correctly stated the month. The 2. The date of interview is June 28, 2011. The resident, responding to the question, “What month are we in right now?” states that it is July. coded 2, accurate within 5 days Coding: C0300B would be . The resident correctly stated the month within 5 days, even though the Rationale: correct month is June. June 28th (day 1) + 4 more days is July 2nd, so July is within 5 days of the interview. 11 October 2018 Page C-

178 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C0300: Temporal Orientation (Orientation to Year, Month, and Day) (cont.) 3. The date of interview is June 25, 2011. The resident, responding to the question, “What month are w e in right now?” states that it is July. Coding : C0300B would be coded 1, missed by 6 days to 1 month . Rationale The resident missed the correct month by six days. June 25th (day 1) + 5 : more days = June 30th. Therefore, the resident’s answer is incorrect within 6 days to 1 month. is June 30, 2011. The resident, responding to the question, “What 4. The date of interview month are we in right now?” states that it is August. . Coding: C0300B would be coded 0, missed by more than 1 month Rationale: The resident missed the month by more than 1 month. The date of interview is June 2, 2011. The resident, responding to the question, “What month 5. are we in right now?” states that it is May. Coding: C0300B would be coded 2, accurate within 5 days . th June 2 minus 5 days = May 29 . The resident correctly stated the month Rationale: within 5 days even though the current month is June. Coding Instructions for C0300C. Able to Report Correct Day of the Week Code 0, resident chooses if the answer is incorrect or the • incorrect, or no answer: not to answer the item. • Code 1, c orrect: if the answer is correct . Examples : “What day of the 1. The day of interview is Monday, June 25, 2011. The interviewer asks week is it today?” The resident responds, “It’s Monday.” . Coding: coded 1, correct C0300C would be Rationale: The resident correctly stated the day of the week. 2. The day of interview is Monday, June 25, 2011. The resident, responding to the question, “What day of the week is it today?” states , “Tuesday.” coded 0, incorrect Coding: C0300C would be . Rationale: The resident incorrectly stated the day of the week. 3. The day of interview is Monday, June 25, 2011. The resident, responding to the question, “What day of the week is it today?” states, “Today is a good day.” coded 0, incorrect C0300C would be . Coding: Rationale: The resident did not answer the question correctly. 12 October 2018 Page C-

179 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0400: Recall Item Rationale Health -related Quality of Life Many persons with cognitive impairment can be helped to recall if provided cues. • Providing memory cues can help maximize individual function and decrease frustration • for those residents who respond. Planning for Care • Care plans should maximize use of cueing for resident who respond to recall cues. This will enhance independence. Steps for Assessment Basic BIMS interview instructions are shown on pages C-3 and C-4. Ask the resident the following : “Let’s go back to an earlier question. What were those three 1. words that I asked you to repeat?” 2. Allow up to 5 seconds for spontaneous recall of each word. For any word that is not correctly recalled after 5 seconds, provide a category cue (refer to 3. t,” pages C-6–C-7 for the definition of category cue). “Steps for Assessmen Category cues should be used only after the resident is unable to recall one or more of the three words. 4. Allow up to 5 seconds after category cueing for each missed word to be recalled. ions Coding Instruct For each of the three words the resident is asked to remember: if the resident can not recall the word even after : • Code 0, no—could not recall being given the category cue or if the resident responds with a nonsensical answer or chooses not to answer the item. if the resident requires the category cue to remember the es, after cueing: Code 1, y • word . • if the resident correctly remembers the word Code 2, yes, no cue required: spontaneously without cueing. 13 October 2018 Page C-

180 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0400: Recall (cont.) Coding Tips • If on the first try (without cueing), the resident names multiple items in a category, one of which is correct, they should be coded as correct for that item. • If, however, the interviewer gives the resident the cue and the resident then names multiple items in that category, the item is coded as could not recall, even if the correct item was in the list. Examples The resident The resident is asked to recall the three words that were initially presented. 1. chooses not to answer the question and states, “I’m tired, and I don’t want to do this anymore.” Coding: C0400A-C0400C would be coded 0, no—could not recall , could not recall for each of the three words. Rationale: Choosing not to answer a question often indicates an inability to answer the question, so refusals are . This is the most accurate coded 0, no—could not recall way to score cognitive function, even though, on occasion, residents might choose not to answer for other reasons. 2. The resident is asked to recall the three words. The resident replies, “Socks, shoes, and bed.” The examiner then cues, “One word was a color.” The resident says, “Oh, the shoes were blue.” C0400A, sock, would be . coded 2, yes, no cue required Coding: The resident’s initial response to the question included “sock.” He is given Rationale: credit for this response, even though he also listed another item in that category (shoes), because he was answering the initial question, without cueing. C0400B, blue, would be coded 1, yes, after cueing Coding: . The resident did not recall spontaneously, but did recall after the category Rationale: . Responses that include the word in a sentence are acceptable. cue was given Coding: C0400C, bed, would be coded 2, yes, no cue required . Rationale: The resident independently recalled the item on the first attempt. The resident answers, “I don’t remember.” 3. The resident is asked to recall the three words. The assessor then says, “One word was something to wear.” The resident says, “Clothes.” s, “Blue.” The assessor The assessor then says, “OK, one word was a color.” The resident say then says, “OK, the last word was a piece of furniture.” The resident says, “Couch.” Coding: C0400A, sock, would be coded 0, no—could not recall . Rationale: The resident did not recall the item, even with a cue. Coding: C0400B, blue, would be coded 1, yes, after cueing . Rationale: The resident did recall after being given the cue. coded 0, no—could not recall . Coding: C0400C, bed, would be Rationale: The resident did not recall the item, even with a cue. 14 October 2018 Page C-

181 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0400: Recall (cont.) The 4. The resident says, “I don’t remember.” The resident is asked to recall the three words. assessor then says, “One word was something to wear.” The resident says, “Hat, shirt, pants, socks, shoe, belt.” Coding: C0400A, sock, would be coded 0, no—could not r ecall . Rationale: After getting the category cue, the resident named more than one item (i.e., a laundry list of items) in the category . The resident’s response is coded as incorrect, even though one of the items was correct, because the resident did not demonstrate recall and likely named the item by chance. C0500: BIMS Summary Score Item Rationale Health -related Quality of Life • The total score: . performance comparison with future and past Allows — Decreases the chance of incorrect labeling of cognitive ability and improves detection — of delirium. — Provides staff with a more reliable estimate of resident function and allows staff interactions with residents that are based on more accurate impressions about resident ability. Planning for Care The BIMS is a brief screener that aids in detecting cognitive impairment. It does not • assess all possible aspects of cognitive impairment. A diagnosis of dementia should only be made after a careful assessment for other reasons for impaired cognitive performance. The fi nal determination of the level of impairment should be made by the resident’s physician or mental health care specialist; however, these practitioners can be provided specific BIMS results and the following guidance: ed with Mini- The BIMS total score is highly correlat Mental State Exam (MMSE; Fols tein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS assessm ent where residents can hear all questions and the resident is not delirious suggest the following distributions: cognitively intact 13-15: moderately impaired 8-12: 0-7: severe impairment 15 October 2018 Page C-

182 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0500: BIMS Summary Score (cont.) • Abrupt changes in cognitive status (as indicative of a delirium) often signal an underlying potentially life threatening illness and a change in cognition may be the only indication of an underlying problem. • Care plans can be more individualized based upon reliable knowledge of resident function. Steps for Assessment After completing C0200-C0400: Add up the values for all questions from C0200 through C0400. 1. 2. Do not add up the score while you are interviewing the resident. Instead, focus your f ull attention on the interview. ions Coding Instruct Enter the total score as a two-digit number. The total possible BIMS score ranges from 00 to 15. If the resident chooses not to answer a specific question(s), that question is coded as • incorrect and the item(s) counts in the total score. If, however, the resident chooses not to answer four or more items, then the interview is coded as incomplete and a staff assessment is completed. • To be considered a completed interview, the resident had to attempt and provide relevant answers to at least four of the questions included in C0200-C0400. To be relevant, a response only has to be r elated to the question (logical); it does not have to be correct. See general coding tips on page C-4 for residents who choose not to participate at all. if (a) the resident chooses not to Code 99, unable to complete interview: • participate in the BIMS, (b) if four or more items were coded 0 because the resident (c) if any of the BIMS items is or chose not to answer or gave a nonsensical response, coded with a dash. e: a zero score does not mean the BIMS was incomplete. To be incomplete, a — Not resident had to choose not to answer or give completely unrelated, nonsensical responses to four or more items. Coding Tips but chooses not to participate in the BIMS and Occasionally, a resident can communicate • . This would be considered an therefore does not attempt any of the items in the section incomplete interview BIMS Summary Score ; enter 99 for C0500, , and complete the staff assessment of mental status. 16 October 2018 Page C-

183 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0500: BIMS Summary Score (cont.) Example 1. The resident’s scores on items C0200-C0400 were as follows: C0200 (repetition) 3 C0300A (year) 2 C0300B (month) 2 C0300C (day) 1 C0400A (recall “sock”) 2 C0400B (recall “blue”) 2 0 C0400C (recall “bed”) coded 12 C0500 would be . Coding: C0600: Should the Staff Assessment for Mental Status (C0700- C1000) Be Conducted? Item Rationale Health -related Quality of Life • Direct or performance -based testing of cognitive function using the BIMS is preferred as it decreases the chance of incorrect labeling of cognitive ability and improves detection of delirium. However, a minority of residents are unable or unwilling to participate in the BIMS. • Mental status can vary among persons unable to communicate or who do not complete the interview. Therefore, report of observed behavior is needed for persons unable to complete the — BIMS interview. — When cognitive impairment is incorrectly diagnosed or missed, appropriate , and therapies may not be offered. communication, activities Planning for Care • Abrupt changes in cognitive status (as indicative of delirium) often signal an underlying potentially life -threatening illness and a change in cognition may be the only indication of an underlying problem. This remains true for persons who are unable to communicate or to complete the — BIMS. • Specific aspects of cognitive impairment, when identified, can direct nursing and function. interventions to facilitate greater independence 17 October 2018 Page C-

184 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C0600: Should the Staff Assessment for Mental Status (C0700- C1000) Be Conducted? (cont.) Steps for Assessment 1. Review whether BIMS Summary Score item (C0500), is coded 99 , unable to complete interview. Coding Instructions • Code 0, n o: if the BIMS was completed and scored between 00 and 15. Skip to C1310. • if the resident chooses not to participate in the BIMS or if four or more es: Code 1, y items were because the resident chose not to answer or gave a nonsensical coded 0 response. Continue to C0700- C1 000 and perform the Staff Assessment for Mental Status . Note : C0500 should be coded 99 . Coding Tips • , should not be If a resident is scored 00 on C0500, C0700-C1000, Staff Assessment is a legitimate value for C0500 and indicates that the interview was completed. 00 , a resident had to choose not to answer or had complete. To have an incomplete interview items . to give completely unrelated, nonsensical responses to four or more BIMS C0700-C1000: Staff Assessment of Mental Status Item 18 October 2018 Page C-

185 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0700-C1000: Staff Assessment of Mental Status Item (cont.) Item Rationale -related Quality of Life Health Cognitive impairment is prevalent among some groups of residents, but not all residents • are cognitively impaired. • Many persons with memory problems can function successfully in a structured, routine environment. Residents may appear to be cognitively impaired because of communication challenges • or lack of interaction but may be cognitively intact. When cognitive impairment is incorrectly diagnosed or missed, appropriate • , and therapies may not be offered. communication, worthwhile activities Planning for Care Abrupt changes in cognitive status (as indicative of a delirium) often signal an underlying • -threatening illness and a change in cognition may be the only indication potentially life of an underlying problem. . By The level and specific areas of impairment affect daily function and care needs • identifying s pecific aspects of cognitive impairment, nursing interventions can be directed toward facilitating greater function. Probing beyond first, perhaps m • istaken, impressions is critical to accurate assessment and . appropriate care planning C0700: Short-term Memory OK Item Rationale Health -related Quality of Life • -minute To assess the mental state of residents who cannot be interviewed, an intact 5 recall (“short- term memory OK”) indicates greater likelihood of normal cognition. • An observed “memory problem” should be taken into consideration in Planning for Care. Planning for Care Identified memory problems typically indicate the need for: • 19 October 2018 Page C-

186 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0700: Short -term Memory OK (cont.) — Assessment and treatment of an underlying related medical problem (particularly if this is a new observation) or adverse medication effect, or — possible evaluation for other problems with thinking — additional nursing support — at times frequent prompting during daily activities additional support during recreational activitie s. — Steps for Assessment -term memory status by asking him or her: 1. Determine the resident’s short • to describe an event 5 minutes after it occurred if you can validate the resident’s response, or • to follow through on a direction given 5 minutes earlier. 2. Observe how often the resident has to be re-oriented to an activity or instructions. Staff members also should observe the resident’s cognitive function in varied daily a ctivities. 3. 4. Observations should be made by staff across all shifts and departments and others with close contact with the resident. 5. Ask direct care staff across all shifts and family or significant others about the resident’s short- term memory status. 6. Review the medical record for clues to the resident’s short -term memory during the look - back period. Coding Instructions Based on all information collected regarding the resident’s short-term memory during the 7-day look-back period, identify and code according to the most representative level of function. • recalled information after 5 minutes. Code 0, if the resident memory OK: Code 1, memory problem: if the most representative level of function shows the • absence of recall after 5 minutes. Coding Tips • If the test cannot be conducted (resident will not cooperate, is non-responsive, etc.) and staff members were unable to make a determination based on observing the resident, use - ”) to indicate that the i nformat ion is not the standard “no information” code (a dash, “ available because it could not be assessed. 20 October 2018 Page C-

187 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0700: Short-term Memory OK (cont.) Example 1. A resident has just returned from the activities room where she and other residents were playing bingo. You ask her if she enjoyed herself playing bingo, but she returns a blank stare . When you ask her if she was just playing bingo, she says, “no.” Code 1, memory problem . C0700, would be coded 1, memory problem . Coding: ce within the past 5 min Rationale: The resident could not recall an event that took pla utes. C0800: Long-term Memory OK Item Rationale Health -related Quality of Life • An observed “long-term memory problem” may indicate the need for emotional support, reminders, and reassurance. It may also indicate delirium if this represents a change from the resident’s baseline. • An observed “long-term memory problem” should be taken into consideration in Planning for Care. Planning for Care • Long -term memory problems indicate the need for: Exclusion of an underlying related medical problem (particularly if this is a new — observation) or adverse medication effect, or — possible evaluation for other problems with thinking — additional nursing support — at times frequent prompting during daily activities additional support during recreational activitie s. — Steps for A ssessment 1. Determine resident’s long -term memory status by engaging in conversation, reviewing memorabilia (photographs, memory books, keepsakes, videos, or other recordings that are meani ngful to the resident) with the resident or observing response to fam ily who visit. 2. Ask questions for which you can validate the answers from review of the medical record, general knowledge, the resident’s family, etc. Ask the resident, “Are you married?” “What is your spouse’s name?” “Do you have any • children ?” “How many?” “When is your birthday?” 21 October 2018 Page C-

188 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] term Memory OK C0800: Long- (cont.) 3. Observe if the resident responds to memorabilia or family members who visit. Observations should be made by staff across all shifts and departments and others with close 4. contact with the resident. 5. Ask direct care staff across all shifts and family or significant others about the resident’s memory status. -back 6. Review the medical record for clues to the resident’s long- term memory during the look period. Coding Instructions • Code 0, memory OK: if the resident accurately recalled long past information. • Code 1, memory problem: if the resident did not recall long past information or did not recall it correctly. Coding Tips • etc.) and cted (resident will not cooperate, is non-responsive, If the test cannot be condu staff were unable to make a determination based on observation of the resident, use the standard “no information ” code (a dash, “ - ”), to indicate that the information is not available because it could not be assessed. C0900: Memory/Recall Ability Item Rationale Health -related Quality of Life “memory/recall problem” with these items may indicate: • An observed — cognitive impairment and the need for additional support with reminders to support or increased independence; — delirium, if this represents a change from the resident’s baseline. Planning for Care • An observed “memory/recall problem” with these items may indicate the need for: — Exclusion of an underlying related medical problem (particularly if this is a new observation) or adverse medication effect; or possible evaluation for other problems with thinking — ; additional signs, directions, pictures, verbal reminders to support the resident’s — independence; 22 October 2018 Page C-

189 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C0900: Memory/Recall Ability (cont.) — an evaluation for acute deli rium if this represents a change over the past few days to weeks; — an evaluation for chronic delirium if this represents a change over the past several weeks to months; or — additional nursing support; — reassurance to reduce anxiety and the need for emotional support, reminders and agitation. Steps for Assessment 1. Ask the resident about each item. For example, “What is the current season? Is it fall, winter, spring, or summer?” “What is the name of this place?” If the resident is not in his or her roo m, ask, “Will you show me to your room?” Observe the resident’s ability to find the way. 2. For residents with limited communication skills, in order to determine the most representative level of function, ask direct care staff across all shifts and family or significant other about recall ability. Ask whether the resident gave indications of recalling these subjects or recognizing them • during the look- back period. 3. Observations should be made by staff across all shifts and departments and others with close contact with the resident. Review the medical record for indications of the resident’s recall of these subjects during the 4. look-back period. Coding Instructions For each item that the resident recalls, check the corresponding answer box. If the resident recalls none, check none of above. • Check C0900A, c urrent season: if resident is able to identify the current season (e.g., correctly refers to weather for the time of year, legal holidays, religious celebrations, etc.). Check C0900B, if resident is able to locate and recognize • location of own room: own room. It is not necessary for the resident to know the room number, but he or she should be able to find the way to the room. • Check C0900C, s taff names and faces: if resident is able to distinguish staff members from family members, strangers, visitors, and other residents. It is not necessary for the resident to know the staff member’s name, but he or she should recognize that the person is a staff member and not the resident’s son or daughter, etc. Check C0900D, that he or she is in a nursing home/hospital swing bed: • To if resident is able to determine that he or she is currently living in a nursing home. check this item, it is not necessary that the resident be able to state the name of the nursing home, but he or she should be able to refer to the nursing home by a term such as a “home for older people,” a “hospital for the elderly,” “a place where people who need extra help live,” etc. Check C0900Z, none of above was recalled. • 23 October 2018 Page C-

190 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C1000: Cognitive Skills for Daily Decision Making Item Rationale DEFINITION Health -related Quality of Life DECISION DAILY MAKING An observed “difficulty with daily decision making” • Includes: choosing clothing; may indicate: knowing when to go to — underlying cognitive impairment and the need for meals; using environmental additional coaching and support or cues to organize and plan (e.g., clocks, calendars, possible anxiety or depression. — posted event notices); in the absence of environmental Planning for Care cues, seeking information • An observed “difficulty with daily decision making” appropriately (i.e. not may indicate the need for: repetitively) from others in order to plan the day; using — a more structured plan for daily activities and awareness of one’s own support in decisions about daily activities, strengths and limitations to — encouragement to participate in structured activities , regulate the day’s events (e.g., asks for help when or necessary); acknowledging an assessment for underlying delirium and medical — need to use appropriate evaluation. assistive equipment such as a walker. Steps for Assessment Review the medical record. Consult family and direct care staff across all shifts. Observe the 1. resident. 2. Observations should be made by staff across all shifts and depar tments and others with close contact with the resident. The intent of this item is to record what the resident is doing (performance). 3. Focus on whether or not the resident is actively making these decisions and not whether staff believes the resident might be capable of doing so. Focus on the resident’s actual performance. 4. Where a staff member takes decision -making responsibility away from the resident regarding tasks of everyday living, or the resident does making, whatever his or her level of capability may be, the not participate in decision resident should be coded as impaired performance in decision making. C- Page October 2018 24

191 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C1000: Cognitive Skills for Daily Decision Making (cont.) Coding Instructions Record the resident’s actual performance in making everyday decisions about tasks or activities of daily living. Enter one number that corresponds to the most correct response. • Code 0, independent: if the resident’s decisions in organizing daily routine and making decisions were consistent, reasonable and organized reflec ting lifestyle, culture, values. • if the resident organized daily routine and made modified independence: Code 1, safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations. • Code 2, moderately impaired: if the resident’s decisions were poor; the resident required reminders, cues, and supervision in planning, organizing, and correcting daily routines. if the resident’s decision severely impaired: Code 3, making was severely • impaired; the resident never (or rarely) made decisions. Tips Coding If the resident “rarely or never” made decisions, despite being provided with • coded 3, severely opportunities and appropriate cues, Item C1000 would be impaired . If the resident makes decisions, although poorly, code 2, moderately impaired . A resident’s considered decision to exercise his or her right to decline treatment or • recommendations by interdisciplinary team members should not be captured as impaired decision making in Item C1000, Cognitive Skills for Daily Decision Making . Examples Mr. B He usually clamps his -verbal. 1. . seems to have severe cognitive impairment and is non mouth shut when offered a bite of food. 2. Mrs. C . does not generally make conversation or make her needs known, but replies “yes” when asked if she would like to take a nap. coded 3, severe Coding: For the above examples, Item C1000 would be impairment . Rationale : In both examples, the residents are primarily non -verbal and do not make their needs known, but they do give basic verbal or non- verbal responses to simple gestures or questions regarding care routines. More information about how the residents function in the environment is needed to definitively answer the questions. From the limited information provided it appears that their communication of choices is limited to very particular circumstances, which would be regarded as “rarely/never” in the relative number of decisions a person could make during the course of a week on the MDS. If such decisions are more frequent or involved more activities, the resident may be only moderately impaired or better. 25 October 2018 Page C-

192 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C1000: Cognitive Skills for Daily Decision Making (cont.) 3. A resident makes her own decisions throughout the day and is consistent and reasonable in her decision -making except that she constantly walks away from the walker she has been using for nearly 2 years. Asked why she doesn’t use her walker, she replies, “I don’t like it. It gets in my way, and I don’t want to use it even though I know all of you think I should.” C1000 would be coded 0, independent . Coding: Rationale: This resident is making and expressing understanding of her own decisions, and her decision is to decline the recommended course of action – using the walker. Other decisions she made throughout the look-back period were consistent and reasonable. routinely participates in coffee hour on Wednesday mornings, and often does not A resident 4. need a reminder. Due to renovations, however, the meeting place was moved to another location in the facility. The resident was informed of this change and was accompanied to the new location by the activities director. Staff noticed that the resident was uncharacteristically agitated and unwilling to engage with other residents or the staff. She eventually left and was found sitting in the original coffee hour room. Asked why she came back to this location, she responded, “the aide brought me to the wrong room, I’ll wait here until they serve the coffee.” Coding: C1000 would be coded 1, modified independent . The resident is independent under routine circumstances. However, when Rationale: the situation was new or different, she had difficulty adjusting. 5. . enjoys congregate meals in the dining and is friendly with the other residents at his Mr. G table. Recently, he has started to lose weight. He appears to have little appetite, rarely eats without reminders and willingly gives his food to other residents at the table. Mr. G. requires frequent cueing from staff to eat and supervision to prevent him from sharing his food. Coding: . C1000 would be coded 2, moderately impaired Rationale: The resident is making poor decisions by giving his food away. He requires cueing to eat and supervision to be sure that he is eating the food on his plate. 26 October 2018 Page C-

193 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C1310: Signs and Symptoms of Delirium Item Rationale -related Quality of Life Health • Delirium is associated with: — increased mortality, — functional decline, development or worsening of incontinence, — s, behavior problem — — withdrawal from activities — rehospitalizations and increased length of nursing home stay. • Delirium can be misdiagnosed as dementia. • A recent deterioration in cognitive function may indicate delirium, which may be reversible if detected and treated in a timely fashion. Planning for Care • Delirium may be a symptom of an acute, treatable illness such as infection or reaction to medications. Prompt detection is essential in order to identify and treat or eliminate the cause. • 27 October 2018 Page C-

194 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH irium (cont.) C1310: Signs and Symptoms of Del Steps for Assessment DEFINITION Observe resident behavior during the items (C0200- BIMS 1. DELIRIUM C0400) for the signs and symptoms of delirium. Some A mental disturbance experts suggest that increasing the frequency of assessment characterized by new or (as often as daily for new admissions) will improve the worsening confusion, acutely disordered expression of level of detection. of in level thoughts, change If the Staff Assessment for Mental Status items ( C0700- 2. or consciousness C1000) was completed instead of the BIMS, ask staff hallucinations. members who conducted the interview about their observations of signs and symptoms of delirium. 3. Review medical record documentation during the 7-day look-back period to determine the resident’s baseline status, fluctuations in behavior, and behaviors that might have occurred during the 7-day look-back period that were not observed during the BIMS. 4. Interview staff, family members and others in a position to observe the resident’s behavior during the 7-day look-back period. For additional guidance on the signs and symptoms of delirium can be found in Appendix C. for C1310A, Acute Mental Status Change Coding Instructions if there is no evidence of acute mental status change from the resident’s Code 0, n • o: baseline. • es: Code 1, y if resident has an alteration in mental status observed in the past 7 days or in the BIMS that represents a change from baseline. Coding Tips • Interview resident’s family or significant others. Review medical record prior to 7-day look-back to determine the resident’s usual mental • status. Examples 1. Resident was admitted to the nursing home 4 days ago. Her family reports that she was alert and oriented prior to admission. Du ring the BIMS interview, she is lethargic and incoherent. 310A would be coded 1, yes . Coding: Item C1 Rationale: There is an acute change of the resident’s behavior from alert and oriented (family report) to lethargic and incoherent during interview. disorientation to time 2. Nurse reports that a resident with poor short- term memory and suddenly becomes agitated, calling out to her dead husband, tearing off her clothes, and being completely disoriented to time, person, and place. Coding: coded 1, yes . Item C1 310A would be cute change in mental status. Rationale: The new behaviors represent an a 28 C- Page October 2018

195 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C1310: Signs and Symptoms of Delirium (cont.) Other Examples of Acute Mental Status Changes A resident who is usually noisy or belligerent becomes quiet, lethargic, or inattentive. • A resident who is normally quiet and content suddenly becomes restless or noisy. • • A resident who is usually able to find his or her way around the unit begins to get lost. Steps for Assessment for C13 10B , Inattention 1. Assess attention separately from level of consciousness. Evidence of inattention may be found during the resident interview, in the medical record, or from family or staff reports of inattention during the 7-day look- back period. An additional step to identify difficulty with attention is to ask the resident to count 2. backwards from 20. Coding Instructions for C1310B, Inattention DEFINITIONS Code 0, b ehavior not present: if the resident • INATTENTION remains focused during the interview and all other Reduced ability to maintain sources agree that the resident was attentive during attention to external stimuli other activities. and shift to appropriately attention to new external Code 1, behavior continuously present, did • Resident seems stimuli. not fluctuate: difficulty focusing if the resident had with unaware or out of touch attention, was easily distracted, or had difficulty dazed, (e.g., environment keeping track of what was said AND the inattention did or darting attention). fixated not vary dur ing the look-back period. All sources must FLUCTUATION agree that inattention was consistently present to select to come The behavior tends this code. and go and/or increase or ehavior present, fluctuates: Code 2, b if • The in severity. decrease over fluctuate may behavior inattention is noted during the interview or any source the of the course interview or reports that the resident had difficulty focusing look - back day the during 7- attention, was easily distracted, or had difficulty Fluctuating behavior period. AND the inattention keeping track of what was said may be by the noted varied during interview or during the look-back period interviewer, by staff reported or if information sources disagree in assessing level of or documented in or family attention. medical record. the C- October 2018 29 Page

196 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C1310: Signs and Symptoms of Delirium (cont.) Examples 1. The resident tries to answer all questions during the BIMS. Although she answers several items incorrectly and responds “I don’t know” to others, she pays attention to the interviewer. Medical record and staff indicate that this is her consistent behavior. Coding: . coded 0, behavior not present Item C1310B would be Rationale: The resident remained focused throughout the interview and this was constant during the look-back period. 2. Questions during the BIMS must be frequently repeated because resident’s attention wanders. This behavior occurs throughout the interview and medical records and staff agree that this behavior is consistently present. The resident has a diagnosis of dementia. Coding: Item C1310B would be coded 1, behavior continuously present, does not fluctuate . The resident’s attention consistently wandered throughout the 7-day look- Rationale: back period. The resident’s dementia diagnosis does not affect the coding. 3. During the BIMS interview, the residen t was not able to focus on all questions asked and his gaze wandered. However, several notes in the resident’s medical record indicate that the resident was attentive when staff communicated with him. Coding: Item C1310B would be coded 2, behavior present, fluctuates . Rationale: Evidence of inattention was found during the BIMS but was noted to be This disagreement shows possible fluctuation in the absent in the medical record. behavior. If any information source reports the symptom as present, C1310B cannot be . coded as 0, Behavior not present 4. Resident is dazedly staring at the television for the first several questions. When you ask a question, she looks at you momentarily but does not answer. Midway through questioning, n and tries to answer. she seems to pay more attentio Coding: Item C1310B would be coded 2, behavior present, fluctuates . Resident’s attention fluctuated during the interview. If as few as one source Rationale: notes fluctuation, then the behavior should be . coded 2 30 October 2018 Page C-

197 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C1310: Signs and Symptoms of Delirium (cont.) Coding Instructions for C1310C, Disorganized Thinking if all sources ehavior not present: • Code 0, b DEFINITION agree that the resident’s thinking was organized and coherent, even if answers were inaccurate or wrong. DISORGANIZED THINKING • Code 1, b ehavior continuously present, did Evidenced by rambling, not fluctuate: if, during the interview and according irrelevant, or incoherent to other sources, the resident’s responses were speech. consistently disorganized or incoherent, conversation was rambling or irrelevant, ideas were unclear or flowed illogically, or the resident unpredictably switched from subject to subject. • Code 2, b if, during the interview or according to ehavior present, fluctuates: other data sources, the resident’s responses fluctuated between disorganized/incoherent and organized/clear. Also code as fluctuating if information sources disagree. Examples The interviewer asks the resident, who is often confused, to give the date, and the response 1. is: “Let’s go ge t the sailor suits!” The resident continues to provide irrelevant or nonsensical responses throughout the interview, and medical record and staff indicate this is constant. coded 1, behavior continuously present, does Coding: C1310C would be not fluctuate . All sources agree that the disorganized thinking is constant. Rationale: 2. The resident responds that the year is 1837 when asked to give the date. The medical record and staff indicate that the resident is never oriented to time but has coherent conversations. For example, staff reports he often discusses his passion for baseball. . coded 0, behavior not present C1310C would be Coding: , even though it was Rationale: The resident’s answer was related to the question incorrect. No other sources report disorganized thinking. 3. The resident was able to tell the interviewer her name, the year and where she was. She was able to talk about the activity she just attended and the residents and staff that also attended. Then the resident suddenly asked the interviewer, “Who are you? What are you doing in my daughter’s home?” coded 2, behavior present, fluctuates C1310C would be . Coding: The resident’s thinking fluctuated between coherent and incoherent at least Rationale: once. If as few as one source notes fluctuation, then the behavior should be coded 2 . C- Page October 2018 31

198 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [C] C1310: Signs and Symptoms of Delirium (cont.) Coding Instructions for C1310D, Altered Level of Consciousness if all sources • Code 0, b ehavior not present: DEFINITIONS agree that the resident was alert and maintained wakefulness during conversation, interview(s), and ALTERED OF LEVEL activities. CONSCIOUSNESS VIGILANT to easily – startles • Code 1, b ehavior continuously present, did any sound or touch; not fluctuate: if, during the interview and according LETHARGIC – repeatedly istently lethargic to other sources, the resident was cons dozes off when you are (difficult to keep awake), stuporous (very difficult to but asking questions, arouse and keep aroused), vigilant (startles easily to any to voice responds or touch; sound or touch), or comatose. STUPOR difficult to – very and keep for arouse aroused • if, Code 2, b ehavior present, fluctuates: interview; the during the interview or according to other sources, the COMATOSE be – cannot For example, resident varied in levels of consciousness. shaking aroused despite and was at times alert and responsive, while at other times shouting. Also code resident was lethargic, stuporous, or vigilant. as fluctuating if information sources disagree. Coding Tips • A diagnosis of coma or stupor does not have to be present for staff to note the behavior in this section. Examples 1. Resident is alert and conversational and answers all questions during the BIMS interview, although not all answers are correct. Medical record documentatio n and staff report during the 7-day look-back period consistently noted that the resident was alert. C1310D would be Coding: coded 0, behavior not present . Rationale: All evidence indicates that the resident is alert during conversation, interview(s) and activities. 2. The resident is lying in bed. He arouses to soft touch but is only able to converse for a short time before his eyes close, and he appears to be sleeping. Again, he arouses to voice or touch but only for short periods during the interview. Information from other sources indicates that this was his condition throughout the look-back period. Coding: C1310D would be coded 1, behavior continuously present, does not fluctuate . The resident’s lethargy was consistent throughout the interview, and there is Rationale: consistent documentation of lethargy in the medical record during the look -back period. C- Page October 2018 32

199 CMS’s RAI Version 3.0 Manual 3: MDS Items [C] CH C1310: Signs and Symptoms of Delirium (cont.) 3. Resident is usually alert, oriented to time, place, and person. Today, at the time of the BIMS interview, resident is conversant at the beginning of the interview but becomes lethargic and difficult to arouse. . Coding: C1310D would be coded 2, behavior present, fluctuates If as few as one The level of consciousness fluctuated during the interview. Rationale: source notes fluctuation, then the behavior should be . coded 2, fluctuating CAM Assessment Scoring Methodology The indication of delirium by the CAM requires the presence of: Item A = 1 OR Item B, C or D = 2 AND Item B = 1 OR 2 AND EITHER Item C = 1 OR 2 Item D = 1 OR 2 OR C-33 October 2018 Page

200 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: SECTION D: MOOD Intent: ms in this section address m ood distress, a serious condition that is The ite underdiagnosed and undertreated in the nursing hom e and is associated with significant morbidity. It is particularly important to identify signs and sympto ms of mood distress among dents because these signs nursing home resi ms can be treata bl e. and sympto It is important to that coding the presence of indicators in Section D does note matically not auto mean that the resident has a diagnosis of depr ession or other mood disorder. Assessors do not make or assign a diagnosis in Section D; they s imply record the presence or absence of specific clinical mood indicators. Facility staff should re cogniz e indicator s and consider them when e thes individu plan. developing the resident’s alized care • Depression can be associated with: — psychological and physical distress (e.g., poor adjustment to the nursing home, loss of independence, chronic illness, inc ed sensiti vity to pain ), reas — decreased in therapy and activities (e.g., caused by isolation), participation care, decreased daily resistance to desire to — decreased functional status (e.g., particip g [A DLs ]), and vities of daily livin ate in acti poorer outcom es (e.g., decreased appet ite, decreased cognitive status). — • Findings suggesting mood distress should lead to: — identifying causes and contributing factors for symptom s, ental — identifying interventions (treatm ent, personal support, or environm modifications) that cou ld addres s symptom s, and residen — ensuring t safety. D0100: Should Resident Mood Interview Be Conducted? Rationale Item Health -related Quality of Life can • Most residents who are capable of com municating questions about how they answer feel. • O btaining info es called “hearing ation about mood directly from the resident, som etim rm rate than o accu bservation alone for identifying the re siden t’s voice,” is more reliable and a mood disorder. Page October 2018 D-1

201 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: D0100: Should Resident Mood Interview Be Conducted? (cont.) ng for Care Planni Sy mptom- speci fic in • rom dire ct resident in ter vie ws will allo w for the formation f incorporation of the resident’s vo ice in the individualiz ed care plan. • If a resident cannot co mm unicate, then Staff M ood Interview (D0500 A-J) should be conducted. Steps for Assessment 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. Determine 2. the resident is rarely/never understood verbally, in writing, or using whether another method . If rarely/never understood, skip to D0500, Staff Assessment of Resident Mood (PHQ-9- OV©). 3. Review Language item (A1100) to determine if the resident needs or wants an interpreter to communicate with doctors or health care staff (A1100 = 1). • If the resident needs or wants an inte rpreter, complete the interview with an interpreter. Coding In structions because the resident is should not be conducted if the interview • Cod e 0, no: rarely/never understood or cannot respond verbally, in writing, or using another method, or an interpreter is needed but not available kip to item D0500, Staff Asses sment of . S © ). Mood (PHQ-9- Resident OV • Cod e 1, y es: if the resident inte rview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an . Continue to item D0200, Resident Mood interpreter is needed, one is available © ). -9 Interview (P HQ Populations Coding Tips and Special • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. If the resident interpreter an interpreter, every effort should be made to hav e an • needs © rprete for the PHQ-9 inter view. If it is not possib le for a needed inte present r to be present on the day of the interview, code D0100 = 0 to indicat e tha t an interview was not -D0650. attempte d an d com plet e ite ms D0500 Includes residents who use American Sign Language (ASL). • Page October 2018 D-2

202 CMS’s RAI Version CH 3: MDS Items [D] 3.0 Manual D0100: Should Resident Mood Interview Be Conducted? (cont.) • If the resident interview was not conducted within the look -back period (preferably the day before or the day of) the ARD, item D0100 must be coded 1, Yes, and the standard “no information” code (a dash “ -”) entered in the resident interview items. • Do not complete the Staff Assessment of Resident Mood items (D0500) if the resident interview should have been conducted, but was not done. • There is one exception to completing the Staff Assessment of Resident Mood items (D0500) in place of the resident interview. This exception is specific to a stand-alone, unscheduled PPS assessment only and is discussed on page 2-60. For this type of assessment only, the resident interview may be conducted up to two calendar days after the ARD. • When coding a stand-alone Change of Therapy OMRA (COT), a standalone End of Therapy OMRA (EOT), or a standalone Start of Therapy OMRA (SOT), the interview items may be coded using the responses provided by the resident on a previous assessment only if the DATE of the interview responses from the previous assessment (as documented in item Z0400) were obtained no more than 14 days prior to the DATE of completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used. Page October 2018 D-3

203 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © D0200: Resident Mood Interview (PHQ-9 ) Item Rationale DEFINITION Quality of Life Health -related 9- ITEM PATIENT HEALTH • be associated with: can Depression QUESTIONNAIRE psychological and physical distress, — © ) -9 (PHQ decreased participation in therapy a nd acti vities, — A validated interview that symptoms screens for of — decreased functional status, and depression. It provides a es. poorer outcom — standardized score severity rating for and a evidence of a Mood disorders are common in nursing hom • es and are disorder. depressive often underdiagnosed and undertreated. ng Planni for Care Findings suggesting mood di • to: d lead s coul stres identifying causes and contributing factors for symptoms and — identifying interventions (treatme — nt, personal support, or environmental modifications) that could address symptoms. D-4 Page October 2018

204 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: (cont.) D0200: Resident Mood Interview (PHQ-9©) Assessment Steps for Look-back period for this item is 14 days. Conduct the interview pre ferably the day before or 1. day of the ARD. Interview any resident when D0100 = 1. 2. 3. Conduct the interview in a private setting. If an interpreter is used du 4. ring resident interviews, the interpreter should not attempt to deter nslated , th e outco me of the in ter view, or the mine the intent behind what is being tra or significance of the resident’s es. Interpreters are p eople who translate oral meaning respons n languag e fro m one language to another. or writte glare 5. dent can see your face. Mi nim ize Sit so that th by directing li ght sources away e resi from the re side nt’s face. 6. sure the resident can hear you. Be ith a hearing i mpai rment should be tested using their usual communication • Residents w as applicab le. devices/techniques, amplifier) • external assistive de vice (headphones or hearing Try if you have any doubt an about hearin g ability. • Minimize background noise. © 7. ministering the PHQ -9 If you are ad form, in paper that the resident can see the print. be sure Provide larg e pri nt or assistive de vi ce (e.g., page m agnifier) if necessary. before beginning. 8. Explain the reason for the in terview Suggested language : “I am going to ask you some questions about your mood and are problems that me common about so feelings over the past 2 weeks. I will also ask known to se em personal, but go along with feeling down. Some of the questions m ight everyone is asked to answer t hem . This will help us provide you with better care.” the response choices with xplain and /or show the interview response choices. A cue card E 9. rly written in la rge print m ight h elp t he resident co mprehend the response choices. clea Suggested language : “I am going to ask you how often you have been bothered by a particular problem over the last 2 weeks. I will give the choices that you see on this you card.” (Say while pointing to cue car d): “0 -1 days —never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14 days —nearl y ever y day.” 10. Inter view t he resi dent. you any of the Suggested language: “Over the last 2 weeks, have bothered by been following problems?” Then, for each question in Mood Interview (D0200): Resident • Read the it em as it is w ritten. • Do not provide definitio ns because the m eaning must be based on the resident’s m inte tation. For example, the resident defines for him self what “tired” rpre eans; the item should be scored based on the resident’s i nterpretation. • Each questio n must be asked in se quence to as sess pre sence (colu mn 1) and frequency (colu the next question. mn 2) before proceeding to • Enter code 9 for any response that is unrelated, inco mprehensible, or incoherent or if the resident’s response is not informative with respect to the item being rated; this is nonsensica l response (e.g., when asked the question about “poor appetite or considered a overeating,” the resident answer s, “I always wi n at poker.”). Page October 2018 D-5

205 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [D] © ) (cont.) D0200: Resident Mood Interview (PHQ-9 the For response, as k the residen t to tel l you how ofte n he or sh e was bothered by yes a • Use the response choice s in D0200 Colum n 2, Symptom 14 days. symptom over the last . Start by asking the resident the num ber Frequenc was bothered y of days that he or she ith categories /descri ptio ns (0 -1 by the symptom and read and show cue card w frequency -11 days—half or more of the days, or —never or 1 day, 2-6 days—several days, 7 days y ever y day). —nearl 12-14 days Instructions Column 1. Sy mptom Presence Coding for Cod e 0, no: if resident indicat • s li sted are not p resent enter 0. Enter 0 in es symptom Column 2 as well. Cod es: if resident indicates sympto ms listed are present enter 1. Enter 0, 1, 2, or 3 • e 1, y in Column 2, Symptom Frequency. • res ponse: if the resident Cod unable or chose not to complete the e 9, no was ent, assessm and/or the facility was unable to complete the responded nonsensically assessment. Leave Column 2, Symptom Frequency, blank. Instructions Column 2. Sy mptom Frequency Coding for whether the Record the resident’s responses as they are stated, regardless of or the resident assessor attributes the symptom to something other than mood. Further evaluation of the clinical relevance of reported symptoms should be explored by the responsibl e clinician. has or never • only Cod e 0, n eve r or 1 day : if the resident indic ates that he or she has experienced the sy mptom on 1 day. that e 1, 2-6 day s ( severa l days): if the resident • es Cod he or she has indicat experienced the sy mptom for 2-6 days. • Code 2, 7- 11 days (half or mo re of the days): if the resi dent in dicates that he or she has experienced the sy for 7 -11 days. mptom • Cod e 3, 12-14 d ays (ne arly ev ery day): if the resi dent indicat es that he or she has experienced the sy mptom for 12-14 days. Coding Special Populations and Tips For question D0200I, Thoughts Tha t Yo u Woul d Be B etter Off Dead or of Hurting • Some Way: Yourself in — The checkbox in item D0350 reminds the assessor to notify a responsible clinician Follow facility (psychologist, physician, protocol for evaluating possible self- etc). har m. — Beginning inter viewers may feel uncomfor table asking th is item because they m ay ay fear upsetting the resident or m the question is too personal. Others m ay feel that worry that it will giv e the resi dent inappropriate ideas. However, are having this residents e found that most s hav xperienced interviewer who E ○ s it. feeling appreciate the opportunity to expres Page October 2018 D-6

206 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [D] © ) (cont.) D0200: Resident Mood Interview (PHQ-9 Asking about thoughts of self- harm the person the idea. It does let ○ does not give is already the resident the provider better understand what feeling. The interviewing approach is to ask the question openly and without ○ best hesitation. If the resident uses e a sy mptom , thi s should be briefly • his or her own words to describ deter that If you the resident is reporting the intended sy mptom but using mine explored. how often he or she was bothered by that to tell you his or her own words, ask him symptom. Select only one frequ ency • ite m. response per • If the resident has difficulty selecting b etween tw o frequenc y responses , code fo r the higher frequency. So me ite ms (e.g., item F) contain more than one phrase. If a res ident gives different • for the different parts of a singl e item, select the highest frequency as the frequencies ha t ite m. score for t may respond to questions: • Residents — verbally, — by pointing to their answers on the cue card, OR — ut their answers. by writing o Interviewing Ti ps and Te chniques erstood or m isund Repeat • isinterpreted. a question if you th ink that it has been m nd will stray f • me residents m ay be eager to talk with you a So rom the topic at hand. When to the topic. a person strays, you should gently guide the conversation back Example: to...”; “I S ay, “That’s interesting, now I need to know...”; “Let’s get back — understand, can tell me about...” you • Validate your understanding of what the residen t is sayin g by ask ing fo r clarification. I understood you — Example: Say, “I thin k I hear you sayin g that ...”; “Let’s see if said... Is that correctly.”; “You ?” right g a single • selecting a frequency respon se, star t by offerin If the resident has difficulty frequency response and follow with a sequence of m ore speci fic questions. This is known as unfolding. — Exampl e: S ay, “ Would you say [nam e symptom] bothered you more than half the days in the past 2 weeks?” ○ If the resident says “yes,” show the cue card and ask whether it bothered him or her every day (12 -14 days) or on half or m ore of the days (7 -11 days). nearly ○ If the resident says “no,” show the cue card and ask whether it bothered him or 1 day). her several days (2 -6 days) or never or 1 day (0- Page October 2018 D-7

207 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [D] © -9 D0200: Resident Mood Interview (PHQ ) (cont.) Noncom • such as “not reall y” sho uld be expl ored. Resid ents m ay be mittal respo nses encouraged tell ms and should be gently you if the sy mptom reluctant to report sy mpto to even if it was only s om e of the ti me. This is known as probing. or bothered him her, asking neutral or nondi rectiv Probe suc h as: by e questions ean ?” — “What do you m “Tell e what you have in m ind.” m — “Tell m e m ore about that.” — e more specific.” — “Please b e an exam ple.” — “Give m So • give a long answer to interview ite ms. To narrow the answer to meti mes respondents the choices available, i t can be usefu l to summari ze their longer answer and then response which response option best applies s is know n a s echoing. ask them . Thi or Overeating Example: D0200E, r App etite Item . The resident responds “the — Poo always cold and it just doesn’t taste like it does at hom e. The doctor won’t let food is me have any salt.” interviewer res ponse: “You’re telling m e the food isn’t what you eat at ○ Possible e and you can’t add salt. Ho w ofte n woul d you sa y tha t you were bothered by hom r-eating during the poor appetite or ove la st 2 weeks?” Example: Item — Little Interest or Pleasure in Doing Thing s . The resident, D0200A, interest little when pleasure in or asked how often he or she has been bothered by doing things, responds, “There’s nothing to do here, all you do is eat, bathe, and don’t do anything I like to do.” They sleep. Possible int erview resp onse: “You’ re saying there isn’t m uch to do here and I ○ you me back later to about so me things talk like to do. Thinking about want to co t 2 weeks ing ove r the pas , ho how you’ve been feel w often have you been bothered by little pleasur e i n doin g things.” interest or — Example: Item D0200B, Feeling Down, Depressed, or Ho peless . The resident , when asked how often he or she has b een bothered by feeling down, depressed, or hopeless, responds: “How would you feel if you were here?” how but mportant that ○ Possible int erview resp onse: “You a sked it is i I would feel, I understand r feelings right now. How often would you say that you have you been bothered by feeling down, depressed, or hopeless during th e las t 2 weeks ?” ite • If the resident has difficulty with longer ms, separate the item into shorter parts, and respond a provide a chance to fter each part. This method, known as disentangling, is helpful t has moderate c ognitiv e i mpair ment but can respond to si mple, direct if a residen questions. — Example: Item D0200E, Poo r App etit e or Overeating . asking: ○ You can simplify this item by “ In the last 2 weeks, how often have you ?” “Or overeating been bothered by poor appetite?” ( pause for a response) Page October 2018 D-8

208 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © ) (cont.) D0200: Resident Mood Interview (PHQ-9 Example: D0200C, Trouble Falling or Sta ying Aslee p, or Sleeping Too Much. Item — You can break the item ○ down as follows: “How often are you having problems asleep?” (pause for response) “Ho w ofte n a re you having problem s staying falling response) “How often do you feel you are sleeping too asleep?” (pause for much?” Item D0200H, Moving or Speaking S o Slowly That Other People Could — Example: ing So Fidget y or Restles s Tha t You Hav Have Noticed. Or the Opposite—Be n e Bee Movin g Aroun d a Lo t Mor e tha n Usua l. s with e you having problem n ar ○ You can simplify this item by asking: “Ho w ofte e noticed ?” (pause for d hav moving or speaking so slowly that other people coul response) “How often have you felt so fidgety or restless that you move around a lot more than usual?” D0300: Total Severity Score Item Rationale DEFINITION -related Quality of Life Health SEVERITY TOTAL The score does not diagnose a mood disorder or • SCORE depression but provides a standard score which can be of the A summary frequency communicated the resident’s physician, other to scores that indicates the ecialis ts for appropriate cli nicia ns a nd m ental hea lth sp extent of depression potential follow up. The score symptoms. does not diagnose a mood re is a su mmary of the • The Total Severity Sco a but provides disorder, © that e th tes indica frequency scores on the PHQ-9 standard of communication extent of potential depression sympto ms and can be clinicians and mental with useful for knowing when to reques t additio nal health specialists. assessment by providers or me ntal health specialists. for Planni ng Care © also s and der ovi e pr y for he a wa provides • Score The P HQ-9 alt h car rity Seve tal To hey are how t s and mptom y and track sy y identif easil s to clinician r ti me. g ove changin October 2018 Page D-9

209 CMS’s RAI Version CH 3: 3.0 Manual MDS Items [D] D0300: Total Severity Score (cont.) for Assessment Steps I: After completing D0200 A- 1. Add the num eric scores across all frequency item s in Resident Mood Interview (D0200) Column 2. 2. Do not add up the score while you are inter viewing the resident. Instead, focus your full atte on the in ter vie w. ntion 3. Th e maximum residen t score is 27 (3 x 9). Coding Instructions the freq nses respo uency • The interview is succes sf ully co mpleted if the re sident an swered © 7 of the 9 ite ms on the PHQ-9 . at least of rview is de If sy mptom frequency is blank for 3 or more it ems, the inte em • ed NOT complete. Total Severity Score should be code d as “99 ” an d the Staff Assessment o f should be conducted. Mood Enter t 00 re as • he total sco will be between a two -digit number. The Total Severity Score and 27 (or “ 99 ” if sy mpto m frequency is blank for 3 or more ite ms). • ailed instructions on m anual The so ftware will calcul ate t he Tot al Severity Sc ore. For det © Severity Scoring Rules. Score Total and examples, see Appendix E: PHQ-9 calculations Coding Tips Special Populations and © Responses to can indicate possible depression. Response s can be interpreted as • PHQ-9 follows: me is suggested if—of the 9 items—5 or more ite ms are — Major Depressive Syndro during the look- back at a frequency of half or more of the days (7-11 days) identified at least one of these, (1) little interes period and re in doing things, or (2) t or pleasu feeling down, depressed, or hopeless is identified at a fre quency of half or more of the -11 days) during the look- period. back days (7 e is suggested ms, (1) feeling down, inor Depressive Syndrom if, of the 9 ite M — or hopeless, (2) trou depressed ep, or sleepin g to o much , or ble falling or staying asle (3) feeling tired or having little energy are id entified at a frequency of half or m ore of the days (7 during the look- back period and at least one of these, (1) little -11 days) or pleasure in interest down, depre ssed, or hopeless is doing things, or (2) feeling identified at a frequency of half or more of the days (7 -11 days). © in changes be To tal Severity Score can severity used to track In addition, PHQ-9 — over tim e. Total Severity Score can be inte rpr eted as fo llows: 1-4: minim al depression 5-9: mild depression 10-14: moderate depression 15-19: moderately severe depression 20-27: severe depression D- 10 October 2018 Page

210 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: D0350: Follow-up to D0200I Rationale Item Health -related Quality of Life This item docum ents if appropriate clinical staff and/or mental health provider were • g bette ed that expressed that he or she had thought s of bein inform r off dead, the resident or hurting him or herself in so me way. e significan It is well-known that untreated depression can caus increased • t distress and factors. mortality the geriatric population beyond the ef fects of other risk in • Although rates of suicide have historically been lower in nursing homes than for -harm comparable individuals living in the commu nity, indirect s elf ning and life threate behaviors, including poor nutrition treat ment refusal are common. and • e can be lifesaving, reducing cognition and treat ment of depression in th e n ursing hom Re to the me and also for tho arged the risk of mort ality within the nu rsi ng ho se disch community. Planning for Care • and treat ment of depression in th e n ursing hom e can be lifesaving, reducing Recognition ality within the nu rsi ng ho me and also for tho se disch arged to the the risk of mort - https://www.agingcare.com/Articles/Suicide -and -the- Elderly community (available at 125788.htm ). Steps for Assessment Better Off 1. Co mplete item D0350 only if item D0200I1 Thoughts That You Would Be Dead, - Hurting y of resident self or of bilit Yourself in Some Way = 1 indicating the possi har m. Coding Instructions • a potential e 0, no: if responsible staff or provider was not informed that there is Cod for resident self -har m. staff • Cod e 1, y es: if responsible or provider was informed that there is a potential for -har t self m. residen D- 11 October 2018 Page

211 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © D0500: Staff Assessment of Resident Mood (PHQ-9-OV ) Item Rationale Health -related Quality of Life © • PHQ-9 of a possible Resident Mo od Interview is preferred as it improves the detection ts are unable or un willing to mood disorder. However, a sm all percentage of p atien © mplete the Resident Mo od Interview . Therefore, staff should co the PHQ-9 complete © PHQ-9-OV Staff Assessment of Mood in thes e instances so tha t an y behaviors, signs, or symptoms of mood di stress are identified. © may s Resident Mood Interview till have a • -9 Persons unable to complete the PHQ mood disorder. od Interview Resident Mo • Even if a re sident was unable to complete the , important , as insights m ay be gained from the responses that wer e obtained during th e interview well as observations of the resident’s behaviors and affect during the interview. presence and frequency as well as staf f observations are • The identification of symptom rm need for and type of ay info important in the detection of mood distress, as they m atm ent. tre • not It is important to note that coding the presence of indi cators in Section D does m r mood disorder. n or othe auto matically essio ean that the resident has a diagnosis of depr D; mply record the they si Assessors do not m ake or assign a d iagnosis in Section presence or abs ence of specific clin ical mood indicators. D- 12 Page October 2018

212 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © ) (cont.) D0500: Staff Assessment of Resident Mood (PHQ-9-OV Alternate means of assessing mood must be used for residents who cannot communi • cate © ate in the PHQ-9 refuse Resident Mood Interview . This or or are unable to particip that inform ation ensures not overlooked. about their mood is Planni for Care ng -9©, scripted interviews with staff en the resident is • complete the PHQ Wh not able to who know the resident well should provide cri tical infor mation for understanding mood and making care planning decisions. Steps for Assessment Look-back period for this is 14 days. item Interview staff from all shifts who know the resident best. Conduct interview in a location 1. that protects resident privacy. © Resident Mood The sa me ad ministration techniq ues outlin ed abo ve fo r the PHQ -9 2. Interview (pages D -4–D-6) and Interviewing Tips & Techniques (pages D-6–D-8) should also be follo wed when staff are interviewed. 3. Encourage staff to report symptom frequency, even i f th e sta ff believes the symptom to be unrelated to depression. mptom listed on the ecific sy responses, focusing the discussion on the sp Explore unclear 4. assessm than expanding into a lengthy clinical evaluation. rather ent 14 t has been in the fa cility for less than 5. If frequency cannot be coded because the residen days, talk to fam ily or significant other and rev iew trans fer reco rds to inform the selection of a frequency code. Examples of Staff Responses That Indicate Need for Follow -up Questioning with the Staff Member 1. D0500A, Little Interest or Pleasure in Doing Things The resident doesn’t really do m uch here. • • The resident spends most of the time in his or her room. 2. D0500B, Feeling or Appearing Down, Depressed, or Hopeless • She’s 95—what can you expect? • How would you feel if you were h ere? 3. D0500C, Trouble Falling or Staying Asleep, or Sleeping Too Much • Her back hurts when she lies down. • He urinates a lot during the night. 4. D0500D, Feeling Tired or Having Little Energy • She’s 95—she’s always sayin g she’ s tired. with having a bad spell his COPD right now. • He’s D- 13 October 2018 Page

213 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © -9- OV ) (cont.) D0500: Staff Assessment of Resident Mood (PHQ 5. D0500E, Poor Appetite or Overeating She has not wanted • eat m uch of anything lately. to • He has a voracious appetite, m ore so than last week. 6. D0500F, Indicating That S/he Feels Bad about Self, Is a Failure, or Has Let Self or Family Down • She does get upset when there’s so mething she can’t do now because of her stroke. • barrassed when he can’t re me mber so mething he thinks he should be able to. He gets em 7. D0500G, Trouble Concentrating on Things, Such as Reading the Newspaper or Watching Television • She says there’s nothing good on TV. • She never watches TV. • He can’t se e t o read a newspaper. 8. D0500H, Moving or Speaking So Slowly That Other People Have Noticed. Or the Opposite — Being So Fidgety or Restless That S/he Has Been Moving Around a Lot More than Usual arthritis His down. him slows • • ething to do. He’s bored and always looking for som 9. D0500I, States That Life Isn’t Worth Living, Wishes for Death, or Attempts to Harm Self She says God should take her already. • • He co mplains that m an was not m eant to live like this. 10. D0500J, Being Short -Tempered, Easily Annoyed • She’s O K i f you know ho w t o approac h her. pain is bad. • He can snap but usually when his • Not with me . • He’s irritable. Coding Instructions for Column 1. Symptom Presence • ms listed Cod e 0, no: if sympto are not present. Enter 0 in Colum n 2, Sympt om Freq uenc y . 0, 1, 2, or 3 in Column t. E nter 2, • Cod e 1, yes: if symptoms listed a re presen Frequency Symptom . D-14 October 2018 Page

214 CMS’s RAI Version MDS Items [D] 3.0 Manual CH 3: © ) (cont.) D0500: Staff Assessment of Resident Mood (PHQ-9-OV for Column Instructions mptom Frequency Coding 2. Sy Cod e 0, n eve r or 1 day : if sta ff indica te that the resident • never or has has experienced mptom on only 1 day. the sy that e 1, 2-6 day s ( severa • if staff i ndicate Cod the reside nt has experien ced l days): the sy mptom for 2-6 days. if staff • 2, 7- 11 days (half or mo re of the days): Code indicate that the resident has experienced the sy mptom for 7 -11 days. • Cod e 3, 12-14 d ays (ne arly ev ery day): if staff indicate that the resident has experienced mptom for 12-14 days. the sy Coding Tips and Special Populations the Ask the staff member being int ervie wed to select how often over the p ast 2 weeks • on the fo eric categories the descriptive and/or num Use rm (e.g., symptom occurred. “nearly or 3 = 12-14 days) to select a frequency response. day” every If you separated a longer into its co mponent parts, select the highest • frequency item rating that is reported. • If the staff me mber has difficulty selecting betwee n tw o frequenc y responses, cod e for the higher frequency. ily or e fam an 14 days, also talk to th for less th the resident has been in the f acility If • inform tion code. significant other and review tra nsfer records to of the frequency selec D0600: Total Severity Score Rationale Item -related Quality of Life Health • Review Item Rationale for D0300, Total Severity Score (page D- 8). © © • ) is adapted to allow the assesso Th e PHQ-9 Observational Version (PHQ-9-OV r to Score for potential depressive sympto rview sta ff and identif y a Total Severity inte ms. Planni ng for Care The score can be communicated among health care providers and used to track symptoms • and how they are changing over time. The score is useful for knowing when to request additional assessment by providers or • mental health specialists for underlying depression. D- 15 October 2018 Page

215 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [D] D0600: Total Severity Score (cont.) Assessment Steps for D0500 A- After J: completing items eric scores across all frequency item s for 1. nt of Mood, Symptom Add the num Staff Assessme Frequency (D0500) Column 2. Maxi mum s core is 2. × 10). 30 (3 structions Coding In is succes sf ully rview if the st af f members were able to answer the f requency The inte completed © . responses of at least 8 out of 10 items on the PHQ -9-OV The so ftware will calcul ate t he Tot al Severity Sc ore. For det ailed instructions on m anual • © lations examples, se e Appendix E: PHQ-9- OV calcu Total Severity Score Scoring and Rules. Tips and Special Populations Coding © • can indicate possible depression. Responses can be interpreted Responses to PHQ-9-OV as follows: ms are if—of the 10 items, 5 or more ite suggested Depressive Syndrome is Major — identified at a frequency of half or more of the days (7-11 days) back during the look- at least (1) little interes t or pleasure in doing things, or (2) period and one of these, feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7 -11 days) during the look-back period. — Minor Depressive Syndrom e is suggested if —of the 10 items, (1) feeling down, depressed or hopeless, (2) trou ble falling or staying asle ep, or sleepin g to o much , or (3) feeling or having little energy are id entified at a frequency of half or m ore of tired the days (7 -11 days) during the look- back period and at least one of these, (1) little or pleasure in interest doing things, or (2) feeling or hopeless is down, depre ssed, identified at a frequency of half or more of the days (7 -11 days). © in can To tal Severity Score severity be used to track changes In addition, PHQ-9 — over tim e. Total Severity Score can be inte rpr eted as fo llows: imal depression 1-4: min 5-9: mild depression 10-14: moderate depression severe depression 15-19: moderately severe depression 20-30: D- 16 October 2018 Page

216 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [D] D0650: Follow-up to D0500I Item Rationale Quality -related of Life Health • This item docum ents if appropriate clinical staff and/or mental health provider were the resident expresse inform y had thoughts of bein g bette r off dead , or ed that d that the or hers elf in some way. hurting him It is well known that untreat ed depression can cause significan t distres • d increased s an mortality the geriatric population beyond the ef fects of other risk factors. in • Although rates of suicide have historically been lower in nursing homes than for the commu nity, indirect s elf -harm and life- threateni ng comparable individuals living in and treat ment refusal are common. behaviors, including poor nutrition Planni ng for Care and treat • e can be lifesaving, reducing ursing hom e n ment of depression in th Recognition the risk of mort rsi ng ho me and also for tho se disch arged to the ality within the nu community (available at https://www.agingcare.com/Articles/Suicide -and -the- Elderly - 125788.htm ). Steps for Assessment 1. Co mplete item D0650 only if item D0500I, States That Life Isn’t Worth Living, Wishes = 1 indicating the possibility for Death, or Attempts to Harm Se lf of residen m. t self -har Coding In structions Cod e 0, no: that informed • there is a potentia l if responsible staff or provider was not for resident self -har m. • for Cod e 1, y es: if responsible staff or provider was informed that there is a potential t self residen m. -har D- 17 October 2018 Page

217 CMS’s RAI Version 3.0 CH 3: Manual MDS Items [E] : BEHAVIOR SECTION E : The items in this section identify behavioral symptoms in the last seven days that may Intent distressing or disruptive to facility residents, staff cause distress to the resident, or may be members or the care environment. These behaviors may place the resident at risk for injury, , and inactivity and may also indicate unrecognized needs, preferences or illness. isolation Behaviors include those that are potentially harmful to the resident himself or herself . The emphasis is identifying behaviors, which does not necessar ily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not . Once the frequency and impact of behavioral symptoms are accurately determined, problematic follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. This section focuses on the resident’s actions, not the intent of his or her behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or minimize the resident’s behavior by presuming intent (e.g., “Mr. A. doesn’t really mean to hurt anyone. He’s just frightened.”) . Resident intent should not be taken into account when coding for items in this section. E0100: Potential Indicators of Psychosis Item Rationale ITIONS DEFIN Health ife -related Quality of L HALLUCINATION • mptoms may be associated with Psychotic sy of the The perception — delirium, that is presence of something — dementia , not actually there. be It may auditory or visual or involve — adverse drug effects , or touch. smells, tastes psychiatric disorders — , and DELUSION — hearing or vision impairment. false A fixed, belief not • Hallucinations and delusions may that shared by others the in the resident holds even — be distressing to residents and families, to the of evidence face — cause disability, . contrary — interfere with delivery of medical, nursing, rehabilitative and personal care, and — lead to dangerous behavior or possible harm. October 2018 Page E-1

218 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0100: Potential Indicators of Psychosis (cont.) Planning for Care Reversible and treatable causes should be identified and addressed promptly . When • the cause is not reversible, the focus of management strategies should be to minimize the amount of disability and distress . Steps for Assessment 7- 1. day look-back period. Review the resident’s medical record for the Interview staff members and others who have had the opportunity to observe the resident in a 2. variety of situations during the 7- day look- back period. 3. Observe the resident during conversations and the structured interviews in other assessment sections and listen for statements indicating an experience of hallucinations, or the expression of false beliefs (delusions). 4. Clarify potentially false beliefs : others to be false (e.g., • When a resident expresses a belief that is plausible but alleged by history indicates that the resident’s husband died 20 years ago, but the resident states her husband has been visiting her every day) , try to verify the facts to determine whether there is reason to believe that it could have happened or whether it is likely that the belief is false. • When a resident expresses a clearly false belief, determine if it can be readily corrected by a simple explanation of verifiable (real) facts (which may only require a simple reminder or reorientation) or demonstration of evidence to the contrary. Do not, however, challenge the resident. • The resident’s response to the offering of a potential alternative explanation is often helpful in determining whether the false belief is held strongly enough to be considered fixed. Coding Instructions Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the presence of a medical diagnosis. Check all that apply. • . A if hallucinations were present in the last 7 days Check E0100A, h allucinations : hallucination is the perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch. : • Check E0100B , delusions t in the last 7 days if delusions were presen . A delusion is a fixed, false belief not shared by others that the resident holds true even in the fa ce of evidence to the contrary. or delusions were present if no hallucinations Check E0100Z, none of the above: • in the last 7 days. Page October 2018 E-2

219 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0100: Potential Indicators of Psychosis (cont.) Codi ng Tips and Special Populations If a belief cannot be objectively shown to be false, or it is not possible to determine • whether it is false, code it as a delusion . do not • If a resident expresses a false belief but easily accepts a reasonable alternative explanation, do not code it as a delusion . If the resident continues to insist that the belief is correct despite an explanation or direct evidence to the contrary, code as a delusion . Examples 1. A resident carries a doll which she believes is her baby and the resident appears upset. When asked about this, she reports she is distressed from hearing her baby crying and thinks she’s hungry and wants to get her a bottle. Coding: E0100A would be checked and E0100B would be checked. Rationale : The resident believes the doll is a baby, which is a delusion, and she hears the doll crying , which is an auditory hallucination. A resident reports that a loud knock on the door. When In fact, there was he heard a gunshot. 2. this is explained to him, he accepts the alternative interpretation of the loud noise. Coding: E0100Z would be checked . Rationale : He misinterpreted a real sound in the external environment . Because he is able to accept the alternative explanation for the cause of the sound, his report of a gunshot is not a fixed false belief and is therefore not a delusion. 3. A resident is found speaking aloud in her room. When asked about this, she states that she is answering a q uestion posed to her by the gentleman in front of her. Staff note that no one is present and that no other voices can be heard in the environment. Coding: E0100A would be checked . Rationale : s that occur in the absence The resident reports auditory and visual sensation of any external stimulus . . Therefore, this is a hallucination 4. A resident announces that he must leave to go to work, because he is needed in his office right away. In fact, he has been retired for 15 years. When reminded of this, he continues to insist that he must get to his office. Coding: E0100B would be checked . Rationale : The resident adheres to the belief that he still works, even after being . Because the belief is held firmly despite an reminded about his retirement status . explanation of the real situation, it is a delusion Page October 2018 E-3

220 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0100: Potential Indicators of Psychosis (cont.) 5. A resident believes she must leave the facility immediately because her mother is w aiting for her to return home. Staff know that, in reality, her mother is deceased and gently remind her that her mother is no longer living. In response to this reminder, the resident acknowl edges, “Oh yes, I remember now. Mother passed away years ago.” Coding: checked . E0100Z would be Rationale : The resident’s initial false belief is readily altered with a simple reminder, suggesting that her mistaken belief is due to forgetfulness (i.e., memory loss ) rather than psychosis. Because it is not a firmly held false belief, it does not fit the definition of a delusion. E0200: Behavioral Symptom—Presence & Frequency Item Rationale Health -related Quality of Life • New onset of behavioral symptoms warrants prompt evaluation, assurance of resident safety, relief of distressing symptoms , and compassionate response to the resident. • Reversible and treatable causes should be identified and addressed promptly. When the cause is not reversible, the focus of management strategies should be to minimize the amount of disability and distress. Planning for Care • Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems—and may therefore require treatment planning and intervention—from those that are not problematic. • These behaviors may indicate unrecognized needs, preferences, or illness. • Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and interventions can be developed to improve the symptoms or reduce their impact. Subsequent assessments and documentation can be compared to baseline to identify • uding response to interventions. changes in the resident’s behavior, incl Page October 2018 E-4

221 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0200: Behavioral Symptom—Presence & Frequency (cont.) Steps for Assessment Review the medical record for the 7- day look-ba ck period. 1. Interview staff, across all shifts and disciplines, as well as others who had close interactions 2. with the resident during the 7- day look- back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Ob serve the resident in a variety of situations during the 7- day look- back period. Coding Instructions • Code 0, b ehavior not exhibited : if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days. • Code 1, behavior of this type occurred 1 -3 days : if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days. • ehavior of this type occurred 4 if : -6 days, but less than daily Code 2, b the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occur on any of those days. Code 3, b ehavior of this type occurred • : if the behavior was exhibited daily daily, regardless of the number or severity of episodes that occur on any of those days. Coding Tips and Special Populations • Code based on whether the symptoms occurred and not based on an interpretation of the behavior’s meaning, cause or the assessor’s judgment that the behavior can be explained or should be tolerated. • Code as present , even if staff have become used to the behavior or view it as typical or tolerable. Behaviors in these categories should be coded as present or not present, whether or not • they might represent a rejection of care. • Item E0200C does not include wandering. Examples 1. Every morning, a nursing assistant tries to help a resident who is unable to dress himself. On the last 4 out of 6 mornings, the resident has hit or scratched the nursing assistant during attempts to dress him. Coding: E0200A would be coded 2, behavior of this type occurred 4- 6 days, but less than daily . the nursing assistant was a physical behav ior directed toward Rationale : Scratching others. Page October 2018 E-5

222 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0200: Behavioral Symptom—Presence & Frequency (cont.) 2. A resident has previously been found rummaging through the clothes in her roommate’s dresser drawer. This behavior has not been observed by staff or reported by others in the last 7 days. . Coding: E0200C would be coded 0, behavior not exhibited : The behavior did not occur during the look-back period. Rationale 3. A resident throws his dinner tray at another resident who repeatedly spit food at him during dinner. This is a single, isolated incident. Coding: E0200A would be coded 1, behavior of this type occurred 1- 3 days of the last 7 days . Throwing a tray was a physical behavior directed toward others. : Rationale exists, the behavior is noted as present because it Although a possible explanation occurred. E0300: Overall Presence of Behavioral Symptoms Item Rationale To determine w hether or not additional items E0500, Impact on Resident , and E0600, Impact on Others, are required to be completed . Steps for Assessment 1. Review coding for item E0200 and follow these coding instructions: Coding Instructions • if E0200A, E0200B, and E0200C all are coded 0, not present. Skip to : Code 0, no Rejection of Care— Presence & Frequency item ( E0800). Code 1, y es: if any of E0200A, E0200B, or E0200C were coded 1, 2, or 3. Proceed to • item ( E0600). complete Impact on Resident item (E0500), and Impact on Others Page October 2018 E-6

223 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0500: Impact on Resident Item Rationale Health -related Quality of Life • Behaviors identified in item E0200 impact the resident’s risk for significant injury, interfere with care or their participation in activities or social interactions . Planning for Care • Identification of the impact of the behaviors noted in E0200 may require treatment planning and intervention. • Subsequent assessments and documentation can be compared to a baseline to identify changes in the resident’s behavior, including response to interventions. Steps for Assessment 1. Consider the previous review of the medical record, staff interviews across all shifts and disciplines, interviews with others who had close interactions with the resident and previous observations of the behaviors identified in E0200 for the 7-day look-back period. of the behavioral symptoms coded in all Code E0500A, E0500B, and E0500C based on 2. E0200. Determine whether those behaviors put the resident at significant risk of physical illness or 3. injury, whether the behaviors significantly interfered with the resident’s care , and/or whether the behaviors significantly interfered with the resident’s participation in activit ies or social interactions. . Did Any of the Identified Symptom(s) Coding Instructions for E0500A Put the Resident at Significant Risk for Physical Illness or Injury? • Code 0, no : if none of the identified behavioral symptom(s) placed the resident at clinically significant risk for a physical illness or injury. if any of the identified behavioral symptom(s) placed the resident at • Code 1, y es: , even if no injury occurred. clinically significant risk for a physical illness or injury Page October 2018 E-7

224 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0500: Impact on Resident (cont.) Did Any of the Identified Symptom(s) Coding Instructions for E0500B. Significantly Interfere with the Resident’s Care? • Code 0, no : if none of the identified behavioral symptom(s) significantly interfered with the resident’s care. • Code 1, yes: if any of the identified behavioral symptom(s) impeded the delivery of essential medical, nursing, rehabilitative or personal care, including but not l imited to assistance with activities of daily living, such as bathing, dressing, feeding , or toileting . Codi ng Instructions for E0500C. Did Any of the Identified Symptom(s) Significantly Interfere with the Resident’s Participation in Activities or Social Interactions? • Code 0, no : if none of the identified symptom(s) significantly interfered with the resident’s p articipation in activities or social interactions. yes: Code 1, the identified behavioral symptom(s) significantly interfered if any of • with or decreased the resident’s participation or caused staff not to include residents in act ivities or social interactions. Coding Tips and Special Populations • For E0500A, code based on whether the risk for physical injury or illness is known to occur commonly under similar circumstances (i.e., with residents who exhibit similar behavior in a similar environment) . Physica l injury is trauma that results in pain or other distressing physical symptoms, impaired organ function, physical disability, or other adverse consequences, regardless of the need for medical, surgical, nursing, or rehabilitative intervention. • For E0500B, code if the impact of the resident’s behavior is impeding the delivery of care to such an extent that necessary or essential care (medical, nursing, rehabilitative or being) personal that is required to achieve the resident’s goals for health and well- ot cann be received safely, completely , or in a timely way without more than a minimal accommodation, such as simple change in care routines or environment. • For E0500C, code if the impact of the resident’s behavior is limiting or keeping the resident from engaging in solitary activities or hobbies, joining groups, or attending programmed activities or having positive social encounters with visitors, other residents, or staff. Examples 1. A resident frequently grabs and scratches staff when they attempt to change her soiled brief, digging her nails into their skin. This makes it difficult to complete the care task. Coding: E0500B would be coded 1, yes . essential personal care. This behavior interfered with delivery of Rationale : Page October 2018 E-8

225 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0500: Impact on Resident (cont.) During the last 7 days, a resident with vascular dementia and severe hypertension, hits staff 2. during incontinent care making it very difficult to change her. Six out of the last seven days the resident refuses all her medication including her antihypertensive. The resident closes her mouth and shakes her head and will not take it even if re-approached multiple times. Coding: E0500A and E0500B would both be coded 1, y es . Rationale: The behavior interfered significantly with delivery of her medical and nursing care and put her at clinically significant risk for physical illness. 3. A resident paces incessantly . When staff encourage him to sit at the dinner table, he returns to pacing after less than a minute, even after cueing and reminders. He is so restless that he cannot sit still long enough to feed himself or receive assistance in obtaining adequate nutrition . . coded 1, yes E0500B would both be E0500A and Coding: : This behavior significantly interfered with personal care (i.e., feeding) and Rationale put t he resident at risk for malnutrition and physical illness. 4. A resident repeatedly throws his markers and card on the floor during bingo. Coding: E0500C would be coded 1, yes . : Rationale y. This behavior interfered with his ability to participate in the activit 5. A resident with severe dementia has continuous outbursts while awake despite all efforts made by staff to address the issue, including trying to involve the resident in prior activities of choice. E0500C would be coded 1, yes Coding: . Rationale : The staff determined the resident’s behavior interfered with the ability to participate in any activities. E0600: Impact on Others E-9 Page October 2018

226 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0600: Impact on Others (cont.) Item Rationale Health -related Quality of Life Behaviors identified in item E0200 put others at risk for significant injury, intrude on • their privacy or activities and/or disrupt their care or living environments. The impact on others is coded here in item E0600. Planning for Care Identification of the behaviors noted in E0200 that have an impact on others may require • treatment planning and intervention. • Subsequent assessments and documentation can be compared with a baseline to identify changes in the resident’s behavior, including response to interventions. Steps for Assessment Consider the previous review of the clinical record, staff interviews across all shifts and 1. disciplines, interviews with others who had close interactions with the resident and previous observations of the behaviors identified in E0200 for the 7-day look-back period. 2. To code E0600, determine if the behaviors identified put others at significant risk of physical r care or illness or injury, intruded on their privacy or activities, and/or interfered with thei living environments. Coding Instructions for E0600A . Did Any of the Identified Symptom(s) Put Others at Significant Risk for Physical Injury? • Code 0, no : if none of the identified behavioral symptom(s) placed staff, visitors , or other residents at significant risk for physical injury. Code 1, the identified behavioral symptom(s) placed staff, visitors, or yes: • if any of other residents at significant risk for physical injury. Coding Instructions for E0600B. Did Any of the Identified Symptom(s) Significantly Intrude on the Privacy or Activity of Others? • Code 0, no : if none of the identified behavioral symptom(s) significantly intruded on the privacy or activity of others. if any of the identified behavioral symptom(s) kept other residents from Code 1, • yes: ot organized or run by staff). enjoying privacy or engaging in informal activities (n Includes coming in uninvited, invading, or forcing oneself on others’ private activities. E- 10 October 2018 Page

227 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0600: Impact on Others (cont.) Coding Instructions for E0600C. Did Any of the Identified Symptom(s) Significantly Disrupt Care or the Living Environment? if none of the identified behavioral symptom(s) significantly disrupt ed • Code 0, no : delivery of care or the living environment. Code 1, yes: if any of the identified behavioral symptom(s) created a climate of • excessive noise or interfered with the receipt of care or participation in organized activities by other residents. Coding Tips and Special Populations • For E0600A, code based on whether the behavior placed others at significant risk f or physical injury. Physical injury is trauma that results in pain or other distressing physical symptoms, impaired organ function, physical disability or other adverse consequences, regardless of the need for medical, surgical, nursing, or rehabilitative intervention. • For E0600B, code based on whether the behavior violates other residents’ privacy or interrupts other residents’ performance of activities of daily living or limits engagement in or enjoyment of informal soc ial or recreational activities to such an extent that it causes the other residents to experience distress (e.g., displeasure or annoyance) or inconvenience, whether or not the other residents complain. • For E0600C, code based on whether the behavior interf eres with staff ability to deliver care or conduct organized activities, interrupts receipt of care or participation in organized activities by other residents, and/or causes other residents to experience distress or adverse consequences. Examples 1. A resident appears to intentionally stick his cane out when another resident walks by. Coding: E0600A would be coded 1, yes ; E0600B and E0600C would be coded 0, no . Rationale : The behavior put the other resident at risk for falling and physical injury. You may also need to consider coding B and C depending on the specific situation in the environment or care setting. 2. A resident, when sitting in the hallway outside the community activity room, continually yells, repeating the same phrase. The yelling can be heard by other residents in hallways and activity/recreational areas but not in their private rooms. Coding: E0600A would be coded 0, no ; E0600B and E0600C would be coded 1, yes . Rationale The behavior does not put others at risk for significant injury. The behavior : does create a climate of excessive noise, disrupting the living environment and the activity of others. E- 11 October 2018 Page

228 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0600: Impact on Others (cont.) A resident repeatedly enters the rooms of other residents and rummages through their 3. personal belon gings . The other residents do not express annoyance . Coding: coded 0, no ; E0600B would be coded 1, E0600A and E0600C would be yes . Rationale : This is an intrusion and violates other residents’ privacy regardless of whether they complain or communicate thei r distress. 4. When eating in the dining room, a resident frequently grabs food off the plates of other residents . Although the other resident’s food is replaced, and the behavior does not compromise their nutrition, other residents become anxious in anticipa tion of this recurring . behavior Coding: ; E0600B and E0600C would be coded 0, no coded 1, E0600A would be yes . Rationale : This behavior violates other residents’ privacy as it is an intrusion on the personal space and property (food tray). In addition, the behavior is pervasive and disrupts the staff ’s ability to deliver nutritious meals in dining room (an organized activity). 5. tries to seize the telephone out of the hand of another resident who is attempting to A resident complete a private conversation. Despite being asked to stop, the resident persists in grabbing the telephone and insisting that he wants to use it. coded 1, Coding: E0600A and E0600C would be coded 0, no ; E0600B would be yes . Rationale : is an intrusion on anot This behavior her resident’s private telephone conversation. 6. A resident begins taunting two residents who are playing an informal card game, yelling that they will “burn in hell” if they don’t stop “gambling.” ; E0600B would be coded 1, Coding: E0600A and E0600C would be coded 0, no yes . Rationale Th e behavior is intruding on the other residents’ game. The game is not an : organized facility event and does not involve care. It is an activity in which the two residents wanted to engage. 7. A resident yells continuously during an exercise group, diverting staff attention so that others participate in and enjoy the activity. cannot Coding: coded 0, no ; E0600C would be coded 1, E0600A and E0600B would be yes . Rationale : This behavior disrupts the delivery of physical care (exercis e) to the group creates an environment of excessive noise . participants and E-12 October 2018 Page

229 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0600: Impact on Others (cont.) 8. A resident becomes verbally threatening in a group discussion activity, frightening other residents. In response to this disruption, staff terminate the discussion group early to avoid eliciting the behavioral symptom. ; E0600C would be coded 1, Coding: E0600A and E0600B would be coded 0, no yes . Rationale : This behavior does not put other residents at risk for significant injury. and limits the However, the behavior restricts full participation in the organized activity, enjoyment of other residents. It also causes fear, thereby disrupting the living environment. E0800: Rejection of Care—Presence & Frequency Item Rationale Health -related Quality of Life • Goals for health and well- being reflect the resident’s wishes and objectives for health, function, and life satisfaction that define an acceptable quality of life for that individual. • The resident’s care preferences reflect desires, wishes, inclinations, or choices for care. Preferences do not have to appear logical or rational to the clinician. Similarly, preferences are not necessarily informed by facts or scientific knowledge and may not be consistent with “good judgment.” It is really a matter of resident choice. When rejection/decline of care is first identified, • the team then investigates and determines the rejection/decline of care is really a matter of resident’s choice. Education is provided and the resident’s choices become part of the plan of care. On future assessments, this behavior would not be coded in this item. • A resident might reject/decline care because the care conflicts with his or her preferences . In such cases, care rejection behavior is not considered a problem that warrants and goals treatment to modify or eliminate the behavior. Care rejection may be manifested by verbally declining, statements of refusal, or through • physical behaviors that convey aversion to, result in avoidance of, or interfere with the receipt of care. E- 13 October 2018 Page

230 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E0800: Rejection of Care—Presence & Frequency (cont.) This type of behavior interrupts or interferes with the • DEFINITIONS of care by disrupting the usual delivery or receipt routines or processes by which care is given, or by REJECTION OF CARE exceeding the level or intensity of resources that are Behavior that interrupts or usually available for the provision of care. with the delivery or interferes of care. rejection Care receipt an caused by ’s rejection of care might be A resident • by manifested may be underlying neurops , or dental ychiatric, medical or verbally declining problem. This can interfere with needed care that is or of refusal statements consistent with the resident’s preferences or established physical behaviors through . In such cases, care rejection behavior may care goals or convey aversion to that be a problem that requires assessment and intervention. result in avoidance of or of receipt interfere with the Planning for Care care. • Evaluation of rejection of care assists the nursing home INTERFERENCE WITH in honoring the resident’s care preferences in order to CARE meet his or her desired health care goals. the delivery or Hindering by disrupting of care receipt consider: ssessment should Follow-up a • the usual routines or whether established care goals clearly reflect the — by which care is processes resident’s preferences and goals and the or by exceeding given, resources or intensity of level whether alternative approaches could be used to — for usually available that are achieve the resident’s care goals. of care. provision the • Determine whether a previous discussion identified an objection to the type of care or the way in which the care was provided. If so, determine to accommodate the resident’s preferences . approaches Steps for Assessment 1. . Review the medical record 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7- day look-back period. 3. Review the record and consult staff to determine whether the rejected care is needed to achieve the resident’s preferences and goals for health and well -being . 4. Review to find out whether the care rejection behavior was previously the medical record and documented in discussions or in care planning with the resident, family addressed , or ’s and determined to be an informed choice consistent with the resident significant other values, preferences, or goals; or whether that the behavior represents an objection to the way care is provided, but acceptable alternative care and/or approaches to care have been identified and employed. 5. If the resident exhibits behavior that appears to communicate a rejection of care (and that rejection behavior has n ot been previously determined to be consistent with the resident’ s values or goals), ask him or her directly whether the behavior is meant to decline or refuse care. E- 14 Page October 2018

231 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: (cont.) E0800: Rejection of Care—Presence & Frequency • If the resident indicates that the intention is to decline or refuse, then ask him or her about goals for health care and well -being . the reasons for rejecting care and about his or her • If the resident is unable or unwilling to respond to questions about his or her rejection of care or goal s for health care and well -being, then interview the family or significant other to ascertain the resident’s health care preferences and goals. Coding Instructions • Code 0, behavior not exhibited : if rejection of care consistent with goals was not exhibited in the last 7 days. • Code 1, b ehavior of this type occurred 1 -3 days : if the resident reject ed care consistent with goals 1 -3 days during the 7 -day look-back period, regardless of the number of episodes that occur red on any one of those days. • Code 2, b ehavior of this type occurred 4 -6 days, but less than daily : if back -day look- during the 7 -6 days the resident rejected care consistent with goals 4 period, regardless of the number of episodes that occur on any one of those days. red • Code 3, b ehavior of this type occurred daily : if the resident rejected care consistent with goals daily in the 7 -day look-back period, regardless of the number of episodes that occurred on any one of those days. Coding Tips and Special Populations • The intent of this item is to ide ntify potential behavioral problems, not situations in which care has been rejected based on a choice that is consistent with the resident’s preferences or goals for health and well- being or a choice made on behalf of the resident by a family maker . member or other proxy decision • Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family) and determined to be consistent with the resident’s values, preferences, or goals. Residents who have made an informed choice about not wanting a particular treatment, procedure, etc., should not be identified as “rejecting care.” Examples A resident with heart failure who recently returned to the nursing home after surgical repair 1. of a hip fracture is offered that she gets too short of . She says physical therapy and declines breath when she tries to walk even a short distance, making physical therapy intolerable. She does not expect to walk again and does not want to try. Her physician has discussed this with her and has indicated that her prognosis for regaining ambulatory function is poor. . coded 0, behavior not exhibited Coding: E0800 would be : Rationale This resident has communicated that she considers physical therapy to be both intolerable and futile. The resident discussed this with her physician. Her choice to not accept physical therapy treatment is consistent with her values and goals for health be coded as rejection of care. not care. Therefore, this would E- 15 October 2018 Page

232 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: —Presence & Frequency E0800: Rejection of Care (cont.) 2. A resident informs the staff that he would rather receive care at home, and the next day he . When staff try to persuade him to return, he calls for a taxi and exits the nursing facility I always swore I’d never go to a nursing home . I’ll get by firmly states, “Leave me alone. with my visiting nurse service at home again.” He is not exhibiting signs of disorientation, confusion, or psychosis and has never been judged incompetent . Coding: E0800 would be coded 0, behavior not exhibited . Rationale : is consistent with his stated preferences and goals for health His departure Therefore, this is not coded as care rejection. care. 3. A resident goes to bed at night without changing out of the clothes he wore during the day . When a nursing assistant offers to help him get undressed, he declines, stating that he prefers to sleep in his clothes tonight. The clothes are wet with urine. This has happened 2 of the past 7 days. The resident was previously fastidious, recently has expressed embarrassment at being i ncontinent, and has care goals that include maintaining personal hygiene and skin integrity. coded 1, behavior of this type occurred 1- E0800 would be . 3 days Coding: : Rationale The resident ’s care rejection behavior is not consistent with his values and goals for health and well -being. Therefore, this is classified as care rejection that occurred twice. 4. A resident chooses not to eat supper one day, stating that the food causes her diarrhea . She says she knows she needs to eat and does not wish to compromi se her nutrition, but she i s more distressed by the diarrhea than by the prospect of losing weight. 3 days . Coding: E0800 would be coded 1, behavior of this type occurred 1- : Rationale Although choosing not to eat is consistent with the resident’s desire to avoid diarrhea, it is also in conflict with her stated goal to maintain adequate nutrition. 5. A resident is given his antibiotic medication prescribed for treatment of pneumonia and immediately spits the pills out on the floor . This resident’s assessment indicates that he does on each of the last 4 days not have any swallowing problems. This happened . The resident’s advance directive indicates that he would choose to take antibiotics to treat a potentially life - threatening infection . Coding: 6 days, E0800 would b e coded 2, behavior of this type occurred 4- but less than daily . : Rationale The behavioral rejection of antibiotics prevents the resident from achieving his stated goals for health care listed in his advance directives. Therefore, the behavior is coded as care rejection. E-16 October 2018 Page

233 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: (cont.) E0800: Rejection of Care—Presence & Frequency A resident who recently returned to the nursing home after s urgery for 6. a hip fracture is offered physical therapy and declines . She states that she wants to walk again but is afraid of falling . This occurred on 4 days during the look-back period. . Coding: E0800 would be coded 2, behavior of this type occurred 4- 6 days : Even though the resident’s health care goal is to regain her ambulatory Rationale status, her fear of falling results in rejection of physical therapy and interferes with her . This would be coded as rejection of care. rehabilitation 7. A resident who previously ate well and prided herself on following a healthy diet has been refusing to eat every day for the past 2 w eeks . She complains that the food is boring and that to eat to maintain her weight and avoid . She says she wants she feels full after just a few bites , but she cannot push herself to eat anymore. getting sick Coding: coded 3, behavior of this type occurred daily . E0800 would be Rationale : The resident’s choice not to eat is not consistent with her goal of weight maintenance and health. Choosing not to eat may be related to a medical condition such as a disturbance of taste sensation, gastrointestinal illnes s, endocrine condition, depressive disorder, or medication side effects . E0900: Wandering—Presence & Frequency Item Rationale Health -related Quality of Life • Wandering may be a pursuit of exercise or a pleasurable leisure activity, or it may be related to tension, anxiety, agitation, or searching. Planning for Care • Determine the frequency of its It is important to assess for reason for wandering. occurrence, and any factors that trigger the behavior or that decrease the episodes. Assess for underlying tension, anxiety, psychosis, drug-induced psychomotor • or unmet need (e.g., for food, fluids, toileting, exercise, pain relief, restlessness, agitation, sensory or cognitive stimulation, sense of security, companionship) that m ay be contributing to wandering. E- 17 October 2018 Page

234 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [E] E0900: Wandering—Presence & Frequency (cont.) Steps for Assessment Review the medical record and interview staff to determine whether wandering occurred 1. during the 7-day look-back period. Wandering is the act of moving (walking or locomotion in a wheelchair) from place to • place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes she must find her mother, who staff know is deceased). If wandering occurred, determine the frequency of the wandering during the 7-day look- back 2. period. Coding Instructions for E0900 behavior not exhibited : if wandering was not exhibited during the 7- day • Code 0, Change in Behavioral or Other Symptoms item (E1100). look-back period. Skip to Code 1, b ehavior of this type occurred 1 -3 days : if the resident wandered on • 1-3 days during the 7- day look-back period, regardless of the number of episodes that Wandering ys. Proceed to answer on any one of those da occurred item —Impact (E1000). • if Code 2, b ehavior of this type occurred 4 -6 days, but less than daily : the resident wandered on 4 -6 days during the 7- day look-back period, regardless of the number of episodes that occur red on any one of those days. Proceed to answer E1000). Wandering —Impact item ( ehavior of this type occurred daily : if the resident wandered daily • Code 3, b red on during the 7-day look-back period, regardless of the number of episodes that occur item ( any one of those days . Proceed to answer Wandering —Impact E1000). Coding Tips and Special Populations • Pacing (repetitive walking with a driven/pressured quality) within a constrained spac e is not included in wandering. Wandering may occur even if resident is in a locked unit. • • Traveling via a planned course to another specific place (such as going to the dining room to eat a meal or to an activity) is not considered wandering. E- 18 October 2018 Page

235 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E1000: Wandering—Impact Answer this item only if E0900, Wandering— Presence & Frequency, w as coded 1 (behavior of this type occurred 1 -3 days), 2 (behavior of this type occurred 4-6 days, but less than daily), or 3 (behavior of this type occurred daily). Item Rationale -related Quality of Life Health Not all wandering is harmful. • • Some residents who wander are at potentially higher risk for entering an unsafe situation. Some residents who wander can cause significant disruption to other residents. • Planning for Care • Care plans should consider the impact of wandering on resident safety and disruption to others. Care planning should be focused on minimizing these issues. • • Determine the need for environmental modifications (door alarms, door barriers, etc.) that ing places the resident at risk. enhance resident safety if wander • Determine when wandering requires interventions to reduce unwanted intrusions on other residents or disruption of the living environment. Steps for Assessment 1. Consider the previous review of the resident’s wandering behaviors identified in E0900 for the 7 -day look-back period. those behaviors put the resident at significant risk of getting into 2. Determine whether potentially dangerous places and/or whether wandering significantly intrudes on the privacy based on clinical judgment for the individual resident. or activities of others Coding Instructions for E1000A . Does the Wandering Place the Resident at Significant Risk of Getting to a Potentially Dangerous Place? • Code 0, no : if wandering does not place the resident at significant risk. of getting to a if the wandering places the resident at significant risk • Code 1, y es: dangerous place (e.g., wandering outside the facility where there is heavy traffic) or encountering a dangerous situation (e.g., wandering into the room of another resident with dementia who is known to become physically aggressive toward intruders). E- 19 October 2018 Page

236 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E1000: Wandering—Impact (cont.) Coding Instructions for E1000B . Does the Wandering Significantly Intrude on the Privacy or Activities of Others? • Code 0, no : if the wandering does not intrude on the privacy or activity of others. if the wandering intrudes on the privacy or activities of others (i.e., if the Code 1, yes: • e of wandering violates other residents’ privacy or interrupts other residents’ performanc activities of daily living or limits engagement in or enjoyment of social or recreation al activities ), whether or not the other resident complains or communicates displeasure or annoyance. Examples 1. A resident wanders away from the nursing home in his pajamas at 3 a.m. When staff members talk to him, he insists he is looking for his wife. This elopement behavior had occurred when he was living at home, and on one occasion he became lost and was missing for 3 days, leading his family to choose nursing home admission for his personal safety. . coded 1, yes Coding: E1000A would be Rationale : the ndering that results in elopement from the nursing home places Wa resident at significant risk of getting into a dangerous situation. 2. A resident wanders away from the nursing facility at 7 a.m. Staff find him crossing a busy . Wh en staff tr street against a red light y to persuade him to return, he becomes angry and says, “My boss called , and I have to get to the office.” When staff remind him that he has been retired for many years, he continues to i nsist that he must get to work. Coding: E1000A would be coded 1, yes . Rationale : This resident’s wandering is associated with elopement from the nursing home and into a dangerous traffic situation. Therefore, this is coded as placing the resident at significant risk of getting to a place that poses a danger . In a ddition, delusions would be checked in item E0100. 3. A resident propels himself in his wheelchair into the room of another resident, blocking the door to the other resident’s bathroom. Coding: E1000B would be coded 1, yes . : Rationale Moving about in this manner with the use of a wheelchair meets the definition of wandering, and the resident has intruded on the privacy of another resident and has interfered with that residen t’s ability to use the bathroom. E1100: Change in Behavioral or Other Symptoms E- 20 October 2018 Page

237 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E1100: Change in Behavioral or Other Symptoms (cont.) Item Rationale -related Quality of Life Health • Change in behavior may be an important indicator of — a change in health status or a change in environmental stimuli, — positive response to treatment, and adverse effects of treatment. — Planning for Care • If behavior is worsening, assessment should consider whether it is related to — new health problems, psychosis, or delirium; worsening of pre- — existing health problems; — a ch ange in environmental stimuli or caregivers that influences behavior; and — adverse effects of treatment. If behaviors are improved, assessment should consider what interventions should be • ffects of treatment). continued or modified (e.g., to minimize risk of relapse or adverse e Steps for Assessment 1. Review res ponses provided to items E0100-E1000 on the current MDS assessment. Compare with responses provided on prior MDS assessment. 2. 3. Taking all of these MDS items into consideration, make a global assessment of the change in behavior from the most recent to the current MDS. 4. Rate the overall behavior as same, improved, or worse. Coding Instructions Code 0, s : ame if overall behavior is the same (unchanged). • Code 1, improved: if overall behavior is improved. • • worse: Code 2, if overall behavior is worse. • Code 3, N/A: i f there was no prior MDS assessment of this resident. Coding Tips For residents with multiple behavioral symptoms, it is possible that different behaviors • will vary in different directions over time. That is, one behavior may improve while another worsens or remains the same. Using clinical judgment, this item should be rated to reflect the overall direction of behavior change, estimating the net effects of multiple behaviors. E- 21 October 2018 Page

238 CMS’s RAI Version 3.0 MDS Items [E] Manual CH 3: E1100: Change in Behavioral or Other Symptoms (cont.) Examples On the prior assessment, the resident was reported to wander on 4 out of 7 days. 1. Because of elopement, the behavior placed the resident at significant risk of getting to a dangerous place. On the current assessmen t, the resident was found to wander on the unit 2 of the last 7 days but has not attempted to exit the unit. Because the resident is no longer attempting to exit the unit, she is at decreased risk for elopement and getting to a dangerous place. However, the resident is now wandering into the rooms of other residents, intruding on their privacy. This requires occasional redirection by staff. Coding: E1100 would be coded 1, improved . Rationale : Although one component of this resident’s wandering behavior is worse because it has begun to intrude on the privacy of others, it is less frequent and less dangerous (without recent elopement) and is therefore improved overall since the last assessment . T he fact that the behavior requires less intense surveillance or intervention by staff also supports the decision to rate the overall behavior as improved. 2. At the time of the last assessment, the resident was ambulatory and would threaten and hit and recently suffered a hip fracture other residents daily. He ulatory. He is not is not amb approaching, threatening, or assaulting other residents. However, the resident is now to assist with dressing and bathing, and is hitting staff members combative when staff try daily. coded 0, same E1100 would be . Coding: Rationale : Alth ough the resident is no longer assaulting other residents, he has begun to assault staff . Because the danger to others and the frequency of these behaviors is the same as before, the overall behavior is rated as unchanged. 3. On the prior assessment, a resident with Alzheimer’s disease was reported to wander on 2 out On the most recent assessment, it was noted of 7 days and has responded well to redirection. that the resident has been wandering more frequently for 5 out of 7 days and has also attempted to elope from the building on two occasions. This behavior places the resident at significant risk of personal harm. The resident has been placed on more frequent location checks and has required additional redirection from staff. He was also provided with an elopement bracelet so that staff will be alerted if the resident attempts to leave the building . The intensity required of staff surveillance because of the dangerousness and frequency of the wandering behavior has signific antly increased. . Coding: E1100 would be coded 2, worse : Rationale Because the danger and the frequency of the resident’s wandering behavior have increased and there were two elopement attempts, the overall behavior is rated as worse. E- 22 October 2018 Page

239 CMS’s RAI Version 3: MDS Items [F] 3.0 Manual CH SECTION F: PREFERENCES FOR CUSTOMARY ROUTINE AND ACTIVITIES Intent: The intent of items in this section is to obtain information regarding the resident’s preferences for his or her daily routine and activit ies. This is best accomplished when the family or significant other, or staff information is obtained directly from the resident or through The information obtained during this interviews if the resident cannot report preferences. interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident’s preferences, and is not meant to be all-inclusive. F0300: Should Interview for Daily and Activity Preferences Be Conducted? Item Rationale -related Quality of Life Health • Most residents capable of communicating can answer questions about what they like. • Obtaining information about preferences directly from the resident, sometimes called way of identifying “hearing the resident’s voice,” is the most reliable and accurate preferences. If a resident cannot communicate, then family or significant other who knows the resident • well may be able to provide useful information about preferences. Planning for Care • 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 r esident provides specific information for individualized daily care and activity planning. Steps for Assessment 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine whether or not resident is rarely/never understood verbally, in writing, or using another method. If the resident is rarely or never understood, attempt to conduct the interview with a family member or significant other. 3. If resident is rarely/never understood and a family member or significant other is not available, skip to item F0800, Staff Ass essment of Daily and Activity Preferences. Conduct the interview during the observation period. 4. Page F October 2018 -1

240 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0300: Should Interview for Daily and Activity Preferences Be Conducted? (cont.) 5. Review Language item (A1100) to determine whether or not the resident needs or wants an interpreter. • If the resident needs or wants an interpreter, complete the interview with an interpreter. Coding Instructions Code 0, n o: if the interview should not be conducted with the resident. This option • should be selec ted for residents who are rarely/never understood, who need an interpreter but one was not available, and who do not have a family member or significant other available for interview. Skip to F0800, (Staff Assessment of Daily and Activity Preferences) . • . This option should be conducted if the resident interview should be Code 1, y es: selected for residents who are able to be understood, for whom an interpreter is not needed or is present, or who have a family member or significant other available for intervi ew. Continue to F0400 (Interview for Daily Preferences) and F0500 (Interview for Activity Preferences). Coding Tips and Special Populations • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. • If the resident needs an interpreter, every effort should be made to have an interpreter If it is not possible for a needed interpreter to be present for the MDS clinical interview. present on the day of the interview a family member or significant other is not , and code F0300 = 0 to indicate interview not attempted , and complete available for interview, the Staff Assessment of Daily and Activity Preferences (F0800) instead of the interview e resident (F0400 and F0500). with th • If the resident interview was not conducted within the look-back period of the ARD, item F0300 must be coded 1, Yes, and the standard “no information” code (a dash “- ”) entered in the resident interview items. – Do not complete the Staff Assessment of Daily and Activity Preferences items (F0700 • F0800) if the resident interview should have been conducted, but was not done. Page F October 2018 -2

241 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0400: Interview for Daily Preferences Item Rationale Health -related Quality of Life • Individuals who live in nursing homes continue to have distinct lif estyle preferences. • A lack of attention to lifestyle preferences can contribute to depressed mood and increased behavior symptoms. • Resident responses that something is important but that they can’t do it or have no choice can provide clues for understanding pain, perceived functional limitations, and perceived environmental barriers. Planning for Care ces. Care planning should be individualized and based on the resident’s preferen • • 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. • Incorporating resident preferences into care planning is a dynamic, collab orative process. Because r esidents may adjust their preferences in response to events and changes in status, the preference assessment tool is inte nded 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. Steps for Assessment: Interview Instructions 1. Interview any resident not screened out by the Should Interview for Daily and Activity Preferences Be Conducted? item (F0300). 2. Conduct the interview in a private setting. Page F October 2018 -3

242 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0400: Interview for Daily Preferences (cont.) Sit so that the 3. resident can see your face. Minimize glare by directing light sources away from the resident’s face. 4. Be sure the resident can hear you. • Resi dents with hearing impairment should be interviewed using their usual communication devices/techniques, as applicable. Try an external assistive device (headphones or hearing amplifier) if you have any doubt • about hearing ability . • Minimize background noise . 5. Explain the reason for the interview before beginning. Suggested language: “I’d like to ask you a few questions about your daily routines. The reason I’m asking you these questions is that the staff here would like to know what ’s important to you. This helps us plan your care around your preferences so that you can have a comfortable stay with us. Even if you’re only going to be here for a few days, we want to make your stay as personal as possible.” . While explaining, also show the resident a clearly Explain the interview response choices 6. written list of the response options, a cue card . for example “I am going to ask you how important various activities and routines Suggested language: are to you while you are in this home. I will ask you to answer using the choices you see on this card [ read the answers while pointing to cue card] : ‘Very Important,’ ‘Somewhat important,’ ‘Not very important,’ ‘Not important at all,’ or ‘Important, but can’t do or no choice. ’” Explain the “Im portant, but can’t do or no choice” response option. Suggested language: “Let me explain the ‘Important, but can’t do or no choice’ answer. You would be important to you, but because of your health or can select this answer if something because of what’s available in this nursing home, you might not be able to do it. So, if I ask you about something that is important to you, but you don’t think you’re able to do it now, answer ‘Important, but can’t do or no choice.’ If you choose this option, it will help us to think about ways we might be able to help you do those things.” Residents may respond to questions 7. • verbally , • by pointing to their answers on the cue card, OR • by writing out their answers . significant others. 8. If resident cannot report preferences, then interview family or Page F October 2018 -4

243 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [F] F0400: Interview for Daily Preferences (cont.) Coding Instructions • Code 1, v ery important: if resident, family, or significant other indicates that the topic is “ very DEFINITION important.” NONSENSICAL • somewhat important: if resident, family, Code 2, RESPONSE or significant other indicates that the topic is Any unrelated, “somewhat i mportant.” incomprehensible, or incoherent response that is • Code 3, not very important: if resident , family , or not informative with respect not very significant other indicates that the topic is “ to the item being rated. important.” • if resident , family other indicates that not important at all: Code 4, , or significant .” the topic is “not important at all Code 5, important, but can’t do or no choice: if resident , family, or significant • y unable to important,” but that he or she is physicall other indicates that the topic is “ participate, or has no choice about participating while staying in nursing home because of nursing home resources or scheduling. responsive: Code 9, no response or non- • , family, or significant other refuses to answer or says he If resident — or she does not know. — If r esident does not give an answer to the question for several seconds and does not an answer. appear to be formulating provides an incoherent or nonsensical answer that does not correspond to — If resident the question. Coding Tips and Special Populations gives nonsensical responses or fails interview is considered incomplete if • The the resident to respond to 3 or more of the 16 items in F0400 and F0500. If the interview is stopped because it is considered incomplete, fill the remaining F0400 and F0500 items with a 9 and proceed to F0600, Daily Activity Preferences Primary Respondent. • No look-back is provided for resident. He or she is being asked about current preferences while in the nursing home but is not limited to a 7-day look-back period to convey what his/her preferences are. • -day look-back period. The facility is still obligated to complete the interview within the 7 -5 Page F October 2018

244 CMS’s RAI Version 3: MDS Items [F] 3.0 Manual CH F0400: Interview for Daily Preferences (cont.) Interviewing Tips and Techniques • Sometimes respondents give long or indirect answers to interview items. To narrow the answer to the response choices available, it can be useful to summarize their longer answer and then ask them which response option best applies. This is known as echoing. • For these questions, it is appropriate to explore residents’ answers and try to understand the reason. Examples for F0400A , How Important Is It to You to Choose What Clothes to Wear (including hospital gowns or other garments provided by the facility)? I’ve always paid attention to my appearance. 1. Resident answers, “It’s very important. ” . F0400A would be coded 1, very im portant Coding: 2. Resident replies, “I leave that up to the nurse. You have to wear what you can handle if you .” have a stiff leg Interviewer echoes, “You leave it up to the nurses. Would you say that, while you are here, choosing what clothes to wear is [pointing to cue card] very important, somewhat important, not very important, not important at all, or that it’s important, but you can’t do it because of your leg? ” ” Well, it would be important to me, but I just can’t do it. Resident responds, “ Coding: F0400A would be coded 5, important, but can’t do or no choice . for F0400B, Examples How Important Is It to You to Take Care of Your Personal Belongings or Things? 1. Resident answers, “ It’s somewhat important. I’m not a DEFINITION perfectionist, but I don’t want to have to look for things.” PERSONAL F0400B would be coded 2, somewhat Coding: BELONGINGS OR important . THINGS important things are at home. ” Resident answers, 2. “All my Possessions such as eyeglasses, hearing aids, Interviewer clarifies, “Your most important things are at clothi ng, jewelry, books, home. Do you have any other things while you’re here that toiletries, knickknacks, you think are important to take care of yourself?” pictures. Resident responds, “Well, my son brought me this CD so that I can listen to music. It is very important to me to take care of that. ” player . coded 1, very important F0400B would be Coding: Page F October 2018 -6

245 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0400: Interview for Daily Preferences (cont.) for F0400C, How Important Is It to You to Choose between a Examples Tub Bath, Shower, Bed Bath, or Sponge Bath? 1. Resident answers, “I like showers.” Interviewer clarifies, “You like showers. Would you say that choosing a shower instead of other types of bathing is very important, somewhat important, not very important, not impo rtant at all, or that it’s important, but you can’t do it or have no choice?” The resident responds, “It’s very important.” F0400C would be coded 1, very important . Coding: 2. Resident answers, “I don’t have a choice. I like only sponge baths, but I have to take shower two times a week.” The interviewer says, “So how important is it to you to be able to choose to have a sponge bath while you’re here?” The resident responds, “Well, it is very important, but I don’t always have a choice because that’s the rule .” . coded 5, important, but can’t do or no choice F0400C would be Coding: for F0400D, How Important Is It to You to Have Snacks Example Available between Meals? 1. Resident answers, “I’m a diabetic, so it’s very important DEFINITIONS I get snacks .” that BED BATH coded 1, very Coding: F0400D would be Bath taken in bed using important . washcloths and water basin or other method in bed. SHOWER Bath taken standing or using gurney or shower chair in a shower room or stall. SPONGE BATH Bath taken sitting or standing at sink. TUB BATH Bath taken in bathtub. SNACK Food available between meals, including between dinner and breakfast. Page F October 2018 -7

246 CMS’s RAI Version 3: MDS Items [F] 3.0 Manual CH F0400: Interview for Daily Preferences (cont.) Example for F0400E, How Important Is It to You to Choose Your Own Bedtime? 1. Resident answers, “At home I used to stay up and watch TV. But here I’m usually in bed by 8. That’s because they get me up so early.” Interviewer echoes and clarifies, “You used to stay up later, but now you go to bed before 8 because you get up so early. Would you say it’s [pointing to cue card] very important, somewhat important, not very important, not important at all, or that it’s important, but you don’t have a choice about your bedtime?” Resident responds, “ I guess it would be important, but I can’t do it because they wake me up so ” early in the morning for therapy and by 8 o’clock at night, I’m tired. F0400E would be Coding: coded 5, important, but can’t do or no choice . Example for F0400F, How Important Is It to You to Have Your Family or a Close Friend Involved in Discussions about Your Care? Resident responds, “They’re not involved. They live in the city. They’ve got to take care of 1. ” their own families. Interviewer replies , “You said that your family and close friends aren’t involved right now. When you think about what you would prefer, would you say that it’s very important, somewhat important, not very important, not important at all, or that it is important but you have no choice or can’t have them involved in decisions about your care?” Resid ent responds, “ It’s somewhat important. ” Coding: F0400F would be coded 2, somewhat important . Example for F0400G, How Important Is It to You to Be Able to Use the Phone in Private? 1. Resident answers “That’s not a problem for me, because I have my own room. If I want to make a phone call, I just DEFINITION shut the door.” PRIVATE TELEPHONE Interviewer echoes and clarifies, “So, you can shut your CONVERSATION door to make a phone call. If you had to rate how important A telephone conversation on be able to use the phone in private, would you say it is to no one can listen in, which it’s very important, somewhat important, not very other than the resident. important, or not important at all? ” Resident responds, “Oh, it’s very important.” coded 1, very important F0400G would be Coding: . Page F October 2018 -8

247 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0400: Interview for Daily Preferences (cont.) Example for F0400H, How Important Is It to You to Have a Place to Lock Your Things to Keep Them Safe? 1. Resident answers, “ I have a safe deposit box at my bank, and that’s where I keep family heirlooms and personal documents.” Interviewer says, “That sounds like a good service. While you are staying here, how important is it to you to have a drawer or locker here ?” Resident responds, “It’s not very important. I’m fine with keeping a ll my valuables at the bank.” . coded 3, not very important F0400H would be Coding: F0500: Interview for Activity Preferences Item Rationale Health -related Quality of Life Activities are a way for individuals to establish meaning in their lives, and the need for • enjoyable activities and pastimes does not change on admission to a nursing home. A lack of opportunity to engage in meaningful and enjoyable activities can result in • boredom, depression, and behavior disturbances. Individuals vary in the activities they prefer, reflecting unique personalities, past • interests, perceived environmental constraints, religious and cultural background, and changing physical and mental abilities . Page F October 2018 -9

248 CMS’s RAI Version CH 3: MDS Items [F] 3.0 Manual F0500: Interview for Activity Preferences (cont.) Planning for Care • 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 activit y 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. DEFINITIONS Coding Instructions • See Coding Instructions on page F-4. READ Coding approach is identical to that for daily Script, Braille, or audio recorded written material. preferences . NEWS Coding Tips and Special Populations News about local, state, national, or international 5. See Coding Tips on page F- • current events. Coding tips include th ose for daily preferences . KEEP UP WITH THE • Include Braille and or audio recorded material when NEWS coding items in F0500A. Stay informed by reading, watching, or listening. Techniques and Interviewing Tips NEWSPAPERS AND See Interview Tips and Techniques on • MAGAZINES page F- 5. Any type, such as Coding tips and techniques are identical to th ose for journalistic, professional, and trade publications in script, . daily preferences Braille, or audio recorded format. October 2018 Page F -10

249 CMS’s RAI Version 3: MDS Items [F] 3.0 Manual CH F0500: Interview for Activity Preferences ( cont.) Examples for F0500A, How Important Is It to You to Have Books (Including Braille and Audio-recorded Format), Newspapers, and Magazines to Read? 1. Resident answers, “Reading is very important to me .” . coded 1, very important Coding: F0500A would be 2. Resident answers, “They make the print so small these days. I guess they are just trying to save money .” Interviewer replies, “The print is small. Would you say that h aving books, newspapers, and magazines to read is very important, somewhat important, not very important, not important at all, or that it is important but you can’t do it because the print is so small? ” answers: “ Resident It would be important, but I can’t do it because of the print.” Coding: F0500A would be coded 5, important, but can’t do or no choice . Example for F0500B, How Important Is It to You to Listen to Music You Like? s, “It’s not important, because all we have in here is TV. They keep it blaring 1. Resident answer all day long. ” Interviewer echoes, “ You’ve told me it’s not important because all you have is a TV. Would you say it’s not very important or not important at all to you to listen to music you like while you are here? Or are you saying that it’s important, but you can’t do it because you don’t have a radio or CD player ?” Resident responds, “ Yeah. I’d enjoy listening to some jazz if I could get a radio.” Coding: F0500B would be coded 5, important, but can’t do or no choice . Examples How Important Is It to You to Be Around for F0500C, Animals Such as Pets? 1. Resident answers, “ It’s very important for me NOT to be around animals . You get hair all around and I might inhale it .” Coding: . F0500C would be coded 4, not important at all 2. I’d love to go home and be around my own animals . I’ve taken care of Resident answers, “ them for years and they really need me.” Interviewer probes, “ You said you’d love to be at home with your own animals. How important is it to you to be around pets while you’re staying he re? Would you say it is [points to card] very important, somewhat important, not very important, not important at all, or is it important, but you can’t do it or don’t have a choice about it.” Resident responds, “ Well, it’s important to me to be around my own dogs, but I can’t be around them. I’d say important but can’t do.” Coding: F0500C would be coded 5, Important, but can’t do or no choice . Although the resident has access to therapeutic dogs brought to the nursing Rationale: ss to the type of pet that is important to him. home, he does not have acce Page F October 2018 -11

250 CMS’s RAI Version 3: MDS Items [F] 3.0 Manual CH F0500: Interview for Activity Preferences (cont.) Example for F0500D , How Important Is It to You to Keep Up with the News? so liberal these days, but it’s important to hear what Resident answers, “Well, they are all 1. they are up to.” Interviewer clarifies, “You think it is important to hear the news. Would you say it is [points to card] very important, somewhat important, or it’s important but you can’t do it or have no choice?” Resident responds, “I guess you can mark me somewhat important on that one.” coded 2, somewhat important Coding: F0500D would be . Example for F0500E , How Important Is It to You to Do Things with Groups of People? I’ve never really liked groups of people. They make me nervous.” 1. Resident answers, “ Interviewer echoes and clarifies, “You’ve never liked groups. To help us plan your activities, would you say that while you’re here, doing things with groups of people is very important, somewhat important, not very important, not important at all, or would it be important to you ?” but you can’t do it because you feel nervous about it Resident responds, “At this point I’d say it’s not very important.” Coding: F0500E would be coded 3, not very important . Example s for F0500F, How Important Is It to You to Do Your Favorite Activities? 1. Resident answers, “Well, it’s very important, but I can’t really do my favorite activities while I’m here . At home, I used to like to play board games, but you need people to play and make it interesting . I also like to sketch, but I don’t have the supplies I need to do that here. I’d say important but no choice.” Coding: F0500F would be coded 5, important, but can’t do or no choice . 2. Resident answers, “ I like to play bridge with my bridge club .” Interviewer probes, “Oh, you like to play bridge with your bridge club. How important is it to you to play bridge while you are here in the nursing home?” Resident responds, “Well, I’m just here for a few weeks to finish my rehabilitation. It’s not very important.” . F0500F would be coded 3, not very important Coding: Page F October 2018 -12

251 CH CMS’s RAI Version 3: MDS Items [F] 3.0 Manual F0500: Interview for Activity Preferences (cont.) Example for F0500G, How Important Is It to You to Go Outside to Get Includes Less Temperate Fresh Air When the Weather Is Good ( Weather if ? Resident Has Appropriate Clothing) 1. Resident answers, “They have such a nice garden here. It’s very important to me to go out there.” Coding: F0500G would be coded 1, very important . for F0500H, How Important Is It to Examples DEFINITIONS You to Participate in Religious Services OUTSIDE or Practices? Any outdoor area in the 1. I’m Jewish . I’m Orthodox, but they Resident answers, “ proximity of the facility, have Reform services here. So I guess it’s not important.” including patio, porch, balcony, sidewalk, courtyard, You’re Orthodox, but the services Interviewer clarifies, “ or garden. offered here are Reform. While you are here, how PARTICIPATE IN important would it be to you to be able to participate in RELIGIOUS SERVICES religious services? Would you say it is very important, Any means of taking part in somewhat important, not very important, not important at religious services or all, or would it be important to you but you can’t or have no practices, such as listening to choice because they don’t offer Orthodox services.” services on the radio or Resident responds, “It’s important for me to go to Orthodox television, attending services services if they were offered, but they aren’t. So, can’t do in the facility or in the or no choice.” community, or private prayer or religious study. Coding: F0500I would be coded 5, important, RELIGIOUS PRACTICES but can’t do or no choice . Rituals associated with Resident answers “My pastor sends taped services to me 2. various religious traditions or faiths, such as washing I don’t participate in that I listen to in my room on Sundays. rituals in preparation for the services here. ” prayer, following kosher Interviewer probes, “You said your pastor sends you taped dietary laws, honoring services. Would you say that it is very important, somewhat holidays and religious important, not very important, or not important at all, to festivals, and participating in you that you are able to listen to those tapes from your communion or confession. pastor?” Resident responds, “Oh, that’s ve ” ry important. F0500I would be Coding: coded 1, very important . -13 Page F October 2018

252 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0600: Daily and Activity Preferences Primary Respondent Rationale Item • This item establishes the source of the information regarding the resident’s preferences. Coding Instructions • Code 1, r esident : if resident was the primary source for the preference questions in F0400 and F0500. • Code 2, family or significant other: if a family member or significant other was the primary source of information for F0400 and F0500. interview could not be completed: Code 9, if F0400 and F0500 could not be • completed by the resident, a family member , or a representative of the resident. F0700: Should the Staff Assessment of Daily and Activity Preferences B e Conducted? Item Rationale Health -related Quality of Life • Resident interview is preferred as it most accurately reflects what the resident views as important. However, a small percentage of residents are unable or unwilling to complete the interview for Daily and Activity Preferences. • Persons unable to complete the preference interview should still have preferences evaluated and considered. Planning for Care • Even though the resident was unable to complete the interview, important insights may be gained from the responses that were obtained, observing behaviors , and observi ng the resident’s affect during the interview. Steps for Assessment Review resident, family, or significant other responses to F0400A-H and F0500A- 1. H. Page F October 2018 -14

253 CMS’s RAI Version CH 3: MDS Items [F] 3.0 Manual F0700: Should the Staff Assessment of Daily and Activity e Conducted? Preferences B (cont.) Coding Instructions items (F0400 and • Interview for Daily and Activity Preferences Code 0, n o: if F0500) was completed by resident, family or significant other . Skip to Section G, Functional Status. • if Code 1, y es: Interview for Daily and Activity Preferences items (F0400 through ere not completed because the resident, family, or significant other was unable F0500) w to answer 3 or more items (i.e. 3 or more items in F0400 through F0500 were coded as 9 or “ -“) . Coding Tips and Special Populations • If the total number of unanswered questions in F0400 through F0500 is equal to 3 or more, the interview is considered incomplete . F0800: Staff Assessment of Daily and Activity Preferences Page F October 2018 -15

254 CMS’s RAI Version 3: MDS Items [F] CH 3.0 Manual F0800: Staff Assessment of Daily and Activity Preferences (cont.) Item Rationale Health -related Quality of Life Alternate means of assessing daily preferences • must be used for residents who cannot communicate . This ensures that information about their preferences is not overlooked. Activities allow residents to establish mea • ning in their lives. A lack of meaningful and enjoyable activities can result in boredom, depression, and behavioral symptoms. Planning for Care giving staff should use observations of resident behaviors to understand resident • Care likes and dislikes in cas es where the resident , or significant other cannot report , family . This allows care plans to be individualized to each resident. the resident’s preferences Steps for Assessment Observe the resident when the care, routines, and activities specified in these items are made 1. available to the resident. 2. Observations should be made by staff across all shifts and departments and others with close contact with the resident. 3. If the resident appears happy or content (e.g., is involved, pays attention, smiles) during an activity listed in Staff Assessment of Daily and Activity Preferences item ( F0800), then that item should be checked. If the resident seems to resist or withdraw when these are made available, then do not check that item. Coding Instructions Check all that apply in the last 7 days based on staff observation of resident preferences. • F0800A. Choosing clothes to wear F0800B. Caring for personal belongings • • F0800C. Receiving tub bath • F0800D. Receiving shower F0800E. Receiving bed bath • • F0800F. sponge bath Receiving • F0800G. Snacks between meals • F0800H. Staying up past 8:00 p.m. • F0800I. Family or significant other involvement in care discussions F0800J. Use of phone in private • • F0800K. Place to lock personal belongings Page F October 2018 -16

255 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [F] F0800: Staff Assessment of Daily and Activity Preferences (cont.) F0800L. Reading books, newspapers, or magazines • F0800M. Listening • to music F0800N. Being around animals such as pets • • F0800O. Keeping up with the news ups of people things with gro Doing • F0800P. • F0800Q. Participating in favorite activities • F0800R. Spending time away from the nursing home • F0800S. Spending time outdoors F0800T. Participating in religious activities or practices • • None of the above F0800Z. Page F October 2018 -17

256 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] : FUNCTIONAL STATUS SECTION G Items in this section assess the need for assistance with activities of daily living Intent: (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, resident and staff opinions regarding functional rehabilitation potential are noted. G0110: Activities of Daily Living (ADL) Assistance Page October 2018 G-1

257 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Item Rationale Health -related Quality of Life DEFINITIONS • Almost all nursing home residents need some physical assistance. In addition, most are at risk of further ADL physical decline. The amount of assistance needed and related Tasks to personal the risk of decline vary from resident to resident. any of the tasks care; listed in G0110A -J and G0120. items , and A wide range of physical, neurological • psychological conditions and cognitive factors can ASPECTS ADL adversely affect physical function. Components ADL of an listed are These activity. L assistance can lead to • Dependence on others for AD next to the activity in the item feelings of helplessness, isolation, diminished self- the example, For set. worth , and loss of control over one’s destiny. of G0110H components eating, drinking, are (Eating) • As inactivity increases, complications such as pressure of nourishment intake and or ulcers, falls, contractures, depression, and muscle means, hydration by other wasting may occur. tube feeding, including total parenteral nutrition and IV Plan ning for Care for hydration. fluids • Individualized care plans should address strengths and ADL SELF - weakness, possible reversible causes such as de- PERFORMANCE conditioning, and adverse side effects of medications or what Measures the resident other treatments. These may contribute to needless loss or what (not did actually he of self -sufficiency. In addition, some neurologic be might she of capable injuries such as stroke may continue to improve for ADL each within doing) months after an acute event. over category the last 7 days according to a performance- • For some residents, cognitive deficits can limit ability scale. based or willingness to initiate or participate in self -care or restrict understanding of the tasks required to complete ADLs. A resident’s potential for maximum function is often underestimated by family, staff , and • the resident. Individualized care plans should be based on an accurate assessment of the resident’s self -performance and the amount and type of support being provided to the resident. • Many residents might require lower levels of assistance if they are provided with appropriate devices and aids, assisted with segmenting tasks, or are given adequate time to complete the task while being provided graduated prompting and assistance. This type of supervision requires skill, time , and patience. 2018 G-2 Page October

258 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Most residents are candidates for nursing -based • DEFINITION rehabilitative care that focuses on maintaining and expanding self-involvement in ADLs. ADL SUPPORT PROVIDED • Graduated prompting/task segmentation (helping the most the Measures support ta sks down into smaller components) and resident break over by staff provided the last allowing the resident time to complete an activity can of 7 days, if that level even often increase functional independence. only occurred support once. Steps for Assessment 1. Review t he documentation in the medical record for the 7-day look- back period. Talk with direct care staff from each shift that has cared for the resident to learn what the 2. as well as the resident does for himself during each episode of each ADL activity definition type and level of staff assistance provided. Rem cus is on the 7-day look- ind staff that the fo back period only. 3. cific in When reviewing records, interviewing staff, and observing the resident, be spe evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed M obility, observe what t he resident is able to do without assistance, and then determine the level of assistance the resident require s from staff for moving to and from a lying position, for turn ing the resident from side to side, and/or for positioning the resident in bed. To cl arify your own understanding and observations about a resident’s performance of an ADL activity (bed mobility, locomotion, transfer, etc.), ask probing questions, beginning G-10 for an example with the general and proceeding to the more specific. See page of using probes when talking to staff. Activities of Daily Living Definitions Bed mobility: how resident moves to and from lying position, turns side or side, and A. positions body while in bed or alternate sleep furniture. B. Transfer: how resident moves between surfaces including to or from: bed, chair, excludes wheelchair, standing position ( to/from bath/toilet) . how resident walks between locations in his/her room. C. Walk in room: : D. how resident walks in corridor on unit. Walk in corridor E. Locomotion on unit : how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair. F. how resident moves to and returns from off-unit locations (e.g., : Locomotion off unit areas set aside for dining, activ ities or treatments). If facility has only one floor , how sufficiency once resident moves to and from distant areas on the floor. If in wheelchair, self- in chair. G-3 Page 2018 October

259 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) G. Dressing : how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses. Eating: how resident eats and drinks, regardless of skill. Do not include eating/drinking H. during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration). I. Toilet use: how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. J. Personal hygiene: how resident maintains personal hygiene, including combing hair, baths brushing teeth, shaving, applying makeup, washing/drying face and hands ( excludes and showers). Coding Instructions For each ADL activity: • Consider all episodes of the activity that occur over a 24-hour period dur ing each day of the 7 -day look-back period, as a resident’s ADL self -performance and the support required may vary from day to day, shift to shift, or within shifts. There are many possible reasons for these variations to occur , including but not limited to, mood, medical condition, relationship issues (e.g., willing to perform for a nursing assistant that he or she likes), and medications. The responsibility of the person completing the assessment, therefore, is to capture the total picture of the resident’s ADL self -performance over the 7-day period, 24 hours a day (i.e., not only how the evaluating clinician sees the resident, but how the resident performs on other shifts as well). • cal In order to be able to promote the highest level of functioning among residents, clini staff must first identify what the resident actually does for himself or herself, noting when assistance is received and clarifying the type (weight -bearing, non- weight -bearing, verbal cueing, guided maneuvering, etc.) and level ion, limited assistance, of assistance (supervis etc.) provided by all disciplines . • If a resident uses special adaptive devices such as a walker, device to assist with donning , code ADL Self - socks, dressing stick, long-handled reacher, or adaptive eating utensils ADL Support Provided based on the level of assistance the resident Performance and requires when using such items . Page October 2018 G-4

260 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) • For the purposes of completing Section G, "facility staff" pertains to direct employees -contracted employees (e.g. rehabilitation staff, nursing agency staff). Thus, and facility does not include individuals hired, compensated or not, by individuals outside of the e, for facility's management and administration. Therefore, facility staff does not includ example, hospice staff, nursing/CNA students, etc. Not including these individuals as facility staff supports the idea that the facility retains the primary responsibility for the care of the resident outside of the arranged services another agency may provide to facility residents. The ADL Self -Performance coding level definitions are intended to reflect real world • situations where slight variations in level of ADL self -performance are common. To assist in coding ADL Self- Performance items, facilities may augment the instructions • G-8. with the algorithm on page part ADL evaluation : Self -Performance, which measures • This section involves a two- how much of the ADL activity the resident can do for himself or herself, and Support Provided, which measures how much facility staff support is needed for the resident to es its own scale; complete the ADL. Each of these sections us therefore, it is recommended that the ADL Self -Performance evaluation (Column 1) be completed for all ADL activities before beginnin g the ADL Support evaluation (Column 2). Coding Instructions for G0110 , Column 1 , ADL Self -Performance every if resident completed activity with no help or oversight : independent • Code 0, -day look -back period and the activity occurred at least three times. during the 7 time • Code 1, supervision: if oversight, encouragement, or cueing was provided three or more times during the last 7 days. if resident was highly involved in activity and received assistance: 2, limited Code • (s) or other non- -bearing assistance weight physical help in g uided maneuvering of limb three or more times during the last 7 days. on if resident performed part of the activity over the • Code 3, extensive assistance: three or more times last 7 days and help of the following type(s) was provided : — Wei ght -bearing support provided three or more times , OR three or more times during part but not all of the performance of activity — Full staff last 7 days. Page October 2018 G-5

261 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) • Code 4, total dependence: if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity and the activity occurred . The resident must be unwilling or unable to perform any part of the three or more times activity over the en tire 7 -day look-back period. • if the activity occurred ctivity occurred only once or twice: Code 7, a fewer . than three times not occur or family and/or non- • Code 8, a ctivity did not occur : if the activity did facility staff provided care 100% of the time for that activity over the entire 7 -day look- back period. The Rule of 3 • The “Rule of 3” is a method that was developed to help determine the appropriate code to document ADL Self-Performance on the MDS. It is very important that staff who complete this section fully understand the components • -Performance coding level definitions, and the Rule of 3. of each ADL, the ADL Self • In order to properly apply the Rule of 3, the facility must first note which ADL activities occurred, how many times each ADL activity occurred, what type and what level of support was required for each ADL activity over the entire 7-day look-back period. • The following ADL Self- Performance coding levels are exceptions to the Rule of 3: Code 0, Independent – Coded only if the resident c — ompleted the ADL activity with no help or oversight every time the ADL activity occurred during the 7- day look- back period and the activity occurred at least three times. full staff — Code 4, Total dependence – Coded only if the resident required of the ADL activity the ADL activity occurred during the every time performance . 7-day look-back period and the activity occurred three or more times — Code 7, Activity occurred only once or twice – Coded if the ADL activity occurred fewer than three times in the 7-day look back period. or — Code 8, Activity did not occur – Coded only i f the ADL activity did not occur for that activity family and/or non-facility staff provided care 100% of the time -day look-back period. over the entire 7 Page October 2018 G-6

262 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Ac tivities of Daily Living (ADL) Assistance (cont.) Instructions for the Rule of 3: When an ADL activity has occurred three or more times , apply the steps of the Rule of 3 below (keeping the ADL coding level definitions and the above exceptions in mind) to determine the code to enter in Column 1, ADL Self -Performance. These steps must be cenario used in sequence. Use the first instruction encountered that meets the coding s ). (e.g., if #1 applies, stop and code that level When an activity occurs 1. three or more times at any one level , code that level. levels, code the most 2. When an activity occurs three or more times at multiple . level that occurred three or more times dependent 3. When an activity occurs three or more times and at multiple levels, but not three times at any one level , apply the following: a. Convert episodes of full staff performance to weight -bearing assistance when applying the third Rule of 3, as long as the full staff performance episodes did not occur every time the ADL was performed in the 7 -day look- back period. It is only when every episode is full staff performance that Total dependence (4) can be coded. Remember, that weight -bearing episodes that occur three or more times or full staff performance that is provided three or more times during part but not all of the last 7 days are included in the ADL Self -Performance coding level definition for Extensive assistance (3). b. When there is a combination of full staff performance and weight -bearing assistance that total three or more times —code extensive assistance (3). c. When there is a combination of full staff performance /weight -bearing assistance, and/or non- weight -bearing assistance that total three or more times —code limited assistance (2). . ervision If none of the above are met, code sup Page October 2018 G-7

263 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] -Performance Rule of 3 Algorithm ADL Self – Review these instructions for Rule of 3 before using the algorithm. Follow steps in sequence and stop at first level that applies. START HERE Start by counting the number of episodes at each ADL Self -Performance Level. * Exceptions to Rule of 3: - The Rule of 3 does not apply when coding Independent (0), Total Dependence (4) or Activity Did Not Occur (8), since these levels must be EVERY time the ADL occurred during the look- back period. - The Rule of 3 does not apply when Activity Occurred Only Once or Twice (7), since the activity did not occur at least 3 times. Rule of 3: *note exceptions for Independent (0) and Total Dependence (4). 1. When an activity occurs 3 or more times at any one level, code that level – *note exceptions for 2. When an activity occurs 3 or more times at multiple levels, code the most dependent level that occurs 3 or more times – Independent (0) and Total Dependence (4). 3. When an activity occurs 3 or more times and at multiple levels, but NOT 3 times at any one level , apply the following in sequence as listed – e 3 or more episodes at any stop at the first level that applies: (NOTE: This 3rd rule only applies if there are NOT ANY LEVELS that ar . DO NOT proceed to 3a, 3b or 3c unless this criteria is met.) one level a. Convert episodes of Total Dependence (4) to Extensive Assistance (3) . . code Extensive Assistance (3) b. When there is a combination of Total Dependence (4) and Extensive Assist (3) tha t total 3 or more times – c. When there is a combination of Total Dependence (4) and Extensive Assist (3) and/or Limited Assistance (2) that total 3 or more times, code Limited Assistance (2). . de Supervision (1) If none of the above are met, co STOP at the First Code That Applies Start algorithm here - No Code 8: Activity Did Not Occur Did the activity occur at least 1 time? Yes No Did the activity occur 3 or more times? Code 7: Activity Occurred Once or Twice Yes Yes Did the resident fully perform the ADL activity without ANY help or oversight from staff Code 0: Independent EVERY time? No fully perform the ADL activity without ANY help or oversight at least 3 times Did the resident Yes Code 1: Supervision AND require help or oversight at any other level, but not 3 times at any other level? (Item 1 Rule of 3 with Independent* exception) No Yes Did resident requi re Total Dependence EVERY time? Code 4: Total Dependence (Item 1 Rule of 3, Total Dependence* exception) No Did the resident require Total Dependence 3 or more times, but not every time? Yes Code 3: Extensive Assistance No sident require Extensive Assistance 3 or more times? Did the re No Yes Did the resident require Limited Assistance 3 or more times? Code 2: Limited Assistance No Yes Did the resident require oversight, encouragement or cueing 3 or more times? Code 1: Supervision No Yes Did the resident require a combination of Total Dependence and Extensive Assistance 3 or Code 3: Extensive Assistance more times but not 3 times at any one level? (Item Rule of 3) 3a and 3b s No Yes Did the resident require a combination of Total Dependence, Extensive Assistance, and/or Limited Code 2: Limited Assistance Rule of 3) c Assistan ce that total 3 or more times bu 3 (Item t not 3 times at any one level? G-8 2018 Page October

264 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Coding Instructions for G0110, Column 2, ADL Support Code for the most support provided over all shifts. Code regardless of how Column 1 ADL S elf - Performance is coded . • Code 0, no setup or physical help from staff: if resident completed activity with no help or oversight. if resident is provided with materials or devices necessary Code 1, setup help only : • 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 : aff if the resident was assisted by one st 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 the • activity did not occur or family and/or non- facility staff provided car e 100% of the time -day period. for that activity over the entire 7 Coding Tips and Special Populations Some residents sleep on • furniture other than a bed (for example, a recliner). Consider assistance received in this alternative bed when coding bed mobility. • Do NOT include the emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag in G0110 I. ween guided maneuvering and weight Differentiating bet -bearing assistance: • determine who is supporting the weight of the resident’s extremity or body . For example, if the staff member supports some of the weight of the resident’s hand while helping the resident to eat (e.g., lifting a spoon or a cup to mouth), or performs part of the activity for If the resident can lift the the resident, this is “weight- bearing” assistance for this activity. utensil or cup, but staff assistance is needed to guide the resident’s hand to his or her mouth, this is guided maneuvering. Do NOT record the staff’s assessment of the resident’s potential capability to perform the • ADL activity. The assessment of potential capability is covered in ADL Functional Item Rehabilitation Potential (G0900). • Do NOT record the type and level of assistance that the resident “should” be receiving according to the written plan of care. The level of assistance actually provided might be very different from what is indicated in the plan. Record what actually happened. • Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. Whether or not the resident ansfer is not body mechanical lift tr holds onto a bar, strap, or other device during the full- part of the transfer activity and should not be considered as resident participation in a transfer. Page October 2018 G-9

265 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Transfers via lifts that require the resident to bear weight during the transfer, such as a • -up lift, should be coded as Extensive Assistance, as the resident participated in the stand transfer and the lift provided weight -bearing support. How a resident turns from side to side, in the bed, during incontinence care, is a • component of Bed Mobility and should not be considered as part of Toileting. • When a resident is transferred into or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses urinal is coded in G0110I, Toilet use the bedpan or . Do NOT • . include assistance provided by family or other visitors • Some examples for coding for ADL Support Setup Help when the activity involves the following: — —handing the resident the bar on a trapeze, s taff raises the ½ rails for Bed Mobility the resident’s use and then provides no further help. — Transfer— giving the resident a transfer board or locking the wheels on a wheelchair for safe transfer. — Locomotion o Walking —handing the resident a walker or cane. o Wheeling —unlocking the brakes on the wheelchair or adjusting foot pedals to facilitate foot motion while wheeling. — Dressing — retrieving clothes from the closet and laying out on the resident’s bed; handing the resident a shirt. at meals; giving one food item at a time. cutting meat and opening containers — Eating — — —handing the resident a bedpan or placing articles necessary for changing Toilet Use an ostomy appliance within reach. Personal Hygiene —providing a washbasin and grooming articles. — Supervision • other — Code S upervision for residents seated together or in close proximity of one an during a meal who receive individual supervision with eating. — General supervision of a dining room is not the same as individual supervision of a . resident and is not captured in the coding for Eating Coding • activity did not occur, 8: — Toileting would be coded 8, activity did not occur : only if elimination did not occur during the entire look- back period, or if family and/or non- facility staff toileted the resident 100% of the time over the entire 7- day look- back period. 8, activity did not occur — Locomotion would be coded : if the resident was on bed rest and did not get out of bed, and there was no locomotion via bed, wheelchair, or other means during the look- back period or if locomotion assistance was provided by -day look- back family and/or non- facility staff 100 % of the time over the entire 7 period. Page October 2018 G-10

266 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) — Eating would be coded 8, activity did n ot occur : if the resident received no nourishment by any route (oral, IV, TPN, enteral) during the 7-day look-back period, if the resident was not fed by facility staff during the 7-day look-back period, or if family and/or non- facility staff fed the resident 100% of the time over the entire 7- day look- back period. activity occurred only once or twice, 7: • Coding Walk in corridor would be coded 7, activity occurred only once or twice : if the — resident came out of the room and ambulated in the hallway for a weekly tub bath but day look otherwise stayed in the room during the 7- -back period. — Locomotion off unit would be coded 7, activity occurred only once or twice : if the resident left the vicinity of his or her room only one or two times to attend an activity in another part of the building. , or IV fluids • Residents with tube feeding, TPN Code extensive assistance (1 or 2 persons): — if the resident with tube feeding, TPN, but did participate in or IV fluids did not participate in management of this nutrition receiving oral nutrition. This is the correct code because the staff completed a portion of the ADL activity for the resident (managing the tube feeding, TPN, or IV fluids). ating: — Code t otally dependent in e only if resident was assisted in eating all food items and liquids at all meals and snacks (including tube feeding delivered totally by staff) and di d not participate in any aspect of eating (e.g., did not pick up finger foods, did not give self tube feeding or assist with swallow or eating procedure) . Example of a Probing Conversation with Staff Example of a probing conversation between the RN Assessment Coordinator and a nursing 1. assistant (NA) regarding a resident’s bed mobility assessment: RN: “Describe to me how Mrs. L. moves herself in bed. By that I mean once she is in bed, how does she move from sitting up to lying down, lying down to sitting up, turning side to side and positioning herself?” NA: “She can lay down and sit up by herself, but I help her turn on her side.” RN: “She lays down and sits up without any verbal instructions or physical help?” NA: “No, I have to remind her to use her trapeze every time. But once I tell her how to do things, she can do it herself.” RN: “How do you help her turn side to side?” NA: “She can help turn herself by g rabbing onto her side rail. I tell her what to do. But she needs me to lift her bottom and guide her legs into a good position.” RN: “Do you lift her by yourself or does someone help you?” “I do it by myself.” NA: RN: “How many times during the last 7 days did you give this type of help?” NA: “Every day, probably 3 times each day.” G- October 2018 Page 11

267 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) In this example, the assessor inquired specifically how Mrs. L. moves to and from a lying position, how she turns from side to side, and how the resident positions herself while in bed. A resident can b e independent in one aspect of bed mobility, yet require extensive assistance in another aspect , so be sure to consider each activity definition fully. If the RN did not probe further, he or she would not have received enough information to make an accurate assessment of the actual assistance Mrs. L . received. This information is important to know and document because accurate coding and supportive documentation provides the basis for reporting on the type and amount of care provided. coded 3 (self obility ADL assistance would be Bed M Coding: -performance) and 2 (support provided), extensive assistance with a one person assist . Examples for G0110A , Bed Mobility Mrs. D . can easily turn and position herself in bed and is able to sit up and lie down without 1. any staff assistance at any time during the 7 -day look-back period. She requires use of a . single side rail that staff place in the up position when she is in bed . G0110A1 would be coded 0, independent : Coding G0110A2 would be coded 1, setup help only . Rationale: -day look- Resident is independent at all times in bed mobility during the 7 back period and needs only setup help. 2. Resident favors lying on her right side. Because she has had a history of skin breakdown, staff must verbally remind her to reposition off her right side daily during the 7-day look- back period. G0110A1 would be coded 1, supervision . Coding: G0110A2 would be coded 0, no setup or physical help from staff . Rationale: Resident req uires staff supervision, cueing, and reminders for repositioning more than three times during the look- back period. Resident favors lying on 3. right side. Because she has had a history of skin breakdown, her times cue the resident and guide (non -weight -bearing assistance) the resident staff must some to place her hands on the side rail and encourage her to change her position when in bed daily over the 7-day look-back period. Coding: . G0110A1 would be coded 2, limited assistance G0110A2 would be coded 2, one person physical assist . - weight Rationale: Resident requires cu eing and encouragement with setup and non- -day look-back period. bearing physical help daily during the 7 G- October 2018 Page 12

268 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) 4. . has slid to the foot of the bed four times during the 7-day look-back period. Two staff Mr. Q members had to physically lift and reposition him toward the head of the bed. Mr. Q . was able to assist by bending his knees and pushing with legs when reminded by staff. . coded 3, extensive assistance Coding: G0110A1 would be coded 3, two+ persons physical assist G0110A2 would be . two staff members on four bearing assistance of Rationale: Resident required weight- occasions during the 7-day look-back period with bed mobility. Mrs. S . is unable to physically turn, sit up, or lie down in bed. Two staff members must 5. physically turn her every 2 hours without any participation at any time from her at any time during the 7-day look-back period. She must be physically assisted to a seated position in bed . when reading G0110A1 would be Coding: . coded 4, t otal dependence wo+ persons physical assist G0110A2 would be coded 3, t . during the 7-day look-back period Rationale: Resident did not participate at any time and required two staff to position her in bed. Examples for G0110B , Transfer 1. When transferring from bed to chair or chair back to bed, the resident is able to stand up from a seated position (without requiring any physical or verbal help) and walk from the bed to chair and chair back to the bed every day during the 7 -day look back period. : G0110B1 would be coded 0, independent . Coding coded 0, no setup or physical help from staff . G0110B2 would be Rationale: Resident is independent each and every time she transferred during the 7- day look-back period and required no setup or physical help from staff. 2. Staff must supervise the resident as she transfers from her bed to wheelchair daily. Staff must bring the chair next to the bed and then remind her to hold on to the chair and position her body slowly . Coding: G0110B1 would be coded 1, supervision . would be coded 1, setup help only . G0110B2 Rationale: Resident requires staff supervision, cueing , and reminders for safe transfer. This activity happened daily over the 7-day look-back period. 3. Mrs. H . is able to transfer from the bed to chair when she uses her walker. Staff place the walker near her bed and then assist the resident with guided maneuvering as she transfers. The resident was noted to transfer from bed to chair six times during the 7-day look-back period. Coding: G0110B1 would be coded 2, limited assistance . G0110B2 would be coded 2, one person physical assist . her walker and provide non- weight -bearing Resident requires staff to set up Rationale: assistance when she is ready to transfer. The activity happened six times during the 7 -day look-back period. G- October 2018 Page 13

269 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] (cont.) G0110: Activities of Daily Living (ADL) Assistance 4. Mrs. B . requires weight -bearing assistance of one staff member to partially lift and support her when being transferred. The resident was noted to have been transferred 14 times in the back period and each time required weight -bearing assistance. 7- day look- Coding: coded 3, extensive assistance . G0110B1 would be G0110B2 would be coded 2, one person physical assist . Rationale: Resident partially participates in the task of transferring. The resident was noted to have transferred 14 times during the 7 -day look- riod, each time requiring back pe -bearing assistance of one staff member. weight Mr . T. is in a physically debilitated state due to surgery. Two staff members must physically 5. him to a reclining chair daily usin g a mechanical lift. Mr. T. is unable to lift and transfer assist or participate in any way. Coding: G0110B1 would be coded 4, total dependence . G0110B2 would be coded 3, two+ persons physical assist . Rationale: Resident di d not participate and required two staff to transfer him out of his The resident was transferred out of bed to the chair daily during the 7- . back day look- bed period. Mrs. D . is post -operative for extensive surgical procedures. Because of her ventilator 6. status in addition to multiple surgical sites, her physician has determined that she dependent During the 7- day look- must remain on total bed rest. back period the resident was not moved from the bed. Coding: G0110B1 would be coded 8, activity did not occur . coded 8, ADL activity itself did not occur would be G0110B2 during entire period . Activity did not occur. Rationale: Mr. M . has Parkinson’s d isease and needs weight -bearing assistance of two staff to tra nsfer 7. iod, Mr. M. was from his bed to his wheel chair. During the 7 -day look- back per transferred once from the bed to the wheelchair and once from wheelchair to bed. Coding: G0110B1 would be coded 7, activity occurred only once or twice . G0110B2 would be coded 3, two+ persons physical assist . back period, with the The activity happened only twice during the look- Rationale: support of two staff members. Page October 2018 G-14

270 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Examples for G0110C , Walk in Room 1. Mr. R. is able to walk freely in his room (obtaining clothes from closet, turning on TV) without any cueing or physical assistance from staff at all during the entire 7 -day look-back period. G0110C1 would be Coding: . coded 0, independent coded 0, no setup or physical help from staff . G0110C2 would be Rationale: Resident is independent. 2. Mr. B . was able to walk in his room daily, but a staff member needed to cue and stand by during ambulation because the resident has had a history of an unsteady gait. Coding: G0110C1 would be coded 1, supervision . would be coded 0, no setup or physical help from staff . G0110C2 Rationale: Resident requires staff supervision, cueing, and reminders daily while walking in his room, but did not need setup or physical help from staff. 3. Mr. K. is able to walk in his room, and, with hand- held assist from one staff member, the resident was noted to ambulate daily during the 7-day look-back period. Coding: G0110C1 would be coded 2, limited assistance . G0110C2 . coded 2, one person physical assist would be Rationale: held ( non- weight -bearing ) assistance of one staff Resident requires hand- member daily for ambulation in his room. 4. Mr. A . has a bone spur on his heel and has difficulty ambulating in his room. He requires staff to help support him when he selects clothing from his closet. During the 7-day look- d the resident was able to ambulate with weight- bearing assistance from one staff back perio member in his room four times . Coding: G0110C1 would be coded 3, extensive assistance . G0110C2 would be coded 2, one person physical assist . Rationale: day The resident was able to ambulate in his room four times during the 7- bearing assistance of one staff member. look-back period with weight- Mr. J . is attending physical therapy for transfer and gait training. He does not ambulate on 5. the unit or in his r oom at this time. He calls for assistance to stand pivot to a commode next to his bed. G0110C1 would be coded 8, activity did not occur . Coding: G0110C2 would be coded 8, ADL activity itself did not occur during entire period . Rationale: Activity did not occur. G- October 2018 Page 15

271 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Examples for G0110D , Walk in Corridor 1. Mr. X. ambulated daily up and down the hallway on his unit with a cane and did not require any setup or physical help from staff at any time during the 7-day look-back period. Coding: G0110D1 would be coded 0, independent . G0110D2 would be coded 0, no setup or physical help from staff . Resident requires no setup Rationale: or help from the staff at any time during the entire 7 -day look-back period. 2. Staff members provided verbal cue ing while resident was walking in the hallway every day during the 7-day look-back period to ensure that the resident walked slowly and safely. coded 1, supervision . Coding: G0110D1 would be would be coded 0, no setup or physical help from staff . G0110D2 Rationale: Resident requires staff supervision, cueing, and reminders daily while ambulating in the hallway during the 7 -day look-back period. A resident had back surgery 2 months ago. Two staff members must physically support the 3. his unsteady gait and balance problem. resident as he is walking down the hallway because of back period the resident was ambulated in the hallway three times During the 7-day look- with physical assist of two staff members. Coding: coded 3, extensive assistance . G0110D1 would be would be coded 3, two+ persons physical assist . G0110D2 The resident was ambulated three times during the 7-day look-back period, Rationale: with the resident partially participating in the task. Two staff members were required to physically support the resident so he could ambulate. 4. Mrs. J . ambulated in the corridor once with supervision and once with non- weight -bearing assistance of one staff member during the 7 -day look-back period. Coding: G0110D1 would be coded 7, activity occurred only once or twice . G0110D2 . would be coded 2, one person physical assist The activity occurred only twice during the look-back period. It does not Rationale: matter that the level of assistance provided by staff was at different levels. During y one staff member. ambulation, the most support provided was physical help b Example for G0110E , Locomotion on Unit 1. day look-back period she did not get out of bed Mrs. L. is on complete bed rest. During the 7- or leave the room. G0110E1 would be Coding: coded 8, activity did not occur . ADL activity itself did not occur during coded 8, G0110E2 would be entire period . The resident was on bed rest during the look-back period and never left her Rationale: room. G- October 2018 Page 16

272 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Examples for G0110F , Locomotion off Unit Mr. R. does not like to go off his nursing unit. He prefers to stay in his room or the day room 1. on his unit. He has visitors on a regular basis, and they visit with him in the day room on the -back period the resident did not leave the unit for any reason. unit. During the 7- day look coded 8, activity did not occur Coding: G0110F1 would be . coded 8, ADL activity itself did not occur during would be G0110F2 entire period . Rationale: Activity did not occur at all . -propel on the unit. On two occasions during -bound and is able to self 2. . is a wheelchair Mr. Q the 7 -day look-back period, he self -propelled off the unit into the courtyard. coded 7, activity occurred only once or twice . Coding: G0110F1 would be coded 0, no setup or physical help from staff . G0110F2 would be Rationale: back The activity of going off the unit happened only twice during the look- period with no help or oversight from staff. Mr. H. enjoyed walking in the nursing home garden when weather permitted. Due to 3. inclement weather during the assessment period, he required multiple levels of assistance on the days he walked through the garden. On two occasions, he required limited assistance for balance of one staff person and on another occasion he only required supervision. On one day he was able to walk through the garden completely by himself. 10F1 would be Coding: G01 1, supervision coded . G0110F2 would be coded 2, one person physical assist . Activity did not occur at any one level for three times and he did not requir e Rationale: ance for at least three times. The most support provided by staff was one physical assist person assist. Example , Dressing for G0110G 1. Mrs. C. did not feel well and chose to stay in her room. She requested to stay in night clothes and rest in bed for the entire 7-day look-back period. Each day, after washing up, Mrs. C. changed night clothes with staff assistance to guide her arms and ass ist in guiding her nightgown over her head and buttoning the front. G0110G1 would be Coding: coded 2, limited assistance . G0110G2 would be coded 2, one person physical assist . Rationale: Resident was highly involved in the activity and changed clothing daily weight -bearing assistance from one staff member during the 7 -day look- back with non- period. G- October 2018 Page 17

273 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Examples for G0110H , Eating 1. After staff deliver Mr. K.’s meal tray, he consumes all food and fluids without any cueing or physical help during the entire 7 -day look-back period. : G0110H1 would be coded 0, independent . Coding coded 0, no setup or physical help from staff G0110H2 would be . Resident i s completely independent Rationale: -day look- in eating during the entire 7 back period. 2. One staff member had to verbally cue the resident to eat slowly and drink throughout each meal during the 7 -day look-back period. Coding: G0110H1 would be . coded 1, supervision G0110H2 coded 0, no setup or physical help from staff . would be Rationale: Resident required staff supervision, cueing, and reminders for safe meal completion daily during the 7-day look-back period. Mr . V. is able to eat by himself. Staff must set up the tray, cut the meat, open containers , and 3. hand him the utensils. Each day during the 7-day look-back period, Mr. V . required more help during the evening meal, as he was tired and less inte rested in completing his meal. In the evening , in addition to encouraging the resident to eat and handing him his utensils and cups, staff must also guide the resident’s hand so he will get the utensil to his mouth. Coding: . coded 2, limited assistance G0110H1 would be coded 2, one person physical assist . G0110H2 would be Resident is unable to complete the evening meal without staff providing him Rationale: weight -bearing assistance daily . non- 4. Mr. F . begins eating each meal daily by himself. During the 7 -day look-back period, a fter he had eaten only his bread, he stated he was tired and unable to complete the meal. One staff member physically supported his hand to bring the food to his mouth and provided verbal cues to swallow the food. The resident was then able to complete the meal. Coding: G0110H1 would be coded 3, extensive assistance . G0110H2 would be coded 2, one person physical assist . Rationale: Resident partially participate d in the task daily at each meal, but one staff membe r provided weight- bearing assistance with some portion of each meal. Mrs. U 5. . is severely cognitively impaire d. She is unable to feed herself. She relied on one staff member for all nourishment during the 7-day look-back period. G0110H1 would be coded 4, total dependence . Coding: G0110H2 would be coded 2, one person physical assist . Resident did not participate and required one staff person to feed her all of Rationale: s during the 7- her meal day look-back period. G- October 2018 Page 18

274 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) 6. Mrs. D. receives all of her nourishment via a gastrostomy tube. She did not consume a ny food or fluid by mouth. During the 7-day look-back period, she did not participate in the gastrostomy nourishment process. G0110H1 would be coded 4, total dependence . Coding: G0110H2 coded 2, one person physical assist . would be During the 7-day look-back period, she did not participate in eating and/or Rationale: receiving of her tube feed during the entire period. She required full staff performance of these functions. Examples for G0110I , Toilet Use 1. . L. transferred herself to the toilet, adjusted her clothing, and performed the necessary Mrs - personal hygiene after using the toilet without any staff assistance daily during the entire 7 day look-back period. : G0110I1 would be coded 0, independent . Coding G0110I2 would be coded 0, no setup or physical help from staff . Rationale: Resident wa s independent in all her toileting tasks . 2. Staff member must remind resident to toilet frequently during the day and to unzip and zip pants and to wash his hands after usi ng the toilet. This occurred multiple times each day during the 7-day look-back period. . coded 1, supervision G0110I1 would be Coding: coded 0, no setup or physical help from staff . G0110I2 would be Resident required staff supervision, cueing and reminders daily. Rationale: 3. Staff must assist Mr. P. to zip his pants, hand him a washcloth, and remind him to wash his hands after using the toilet daily. This occurred multiple times each day during the 7- day look-back period. Coding: G0110I1 would be coded 2, limited assistance . G0110I2 would be coded 2, one person physical assist . -bearing activities to complete -weight red staff to perform non Rationale: Resident requi -day look-back period. the task multiple times each day during the 7 4. Mrs . M. has had recent bouts of vertigo. During the 7-day look-back period, the resident bearing support to required one staff member to assist and provide weight- her as she transfe rred to the bedside commode four times. Coding: G0110I1 would be coded 3, extensive assistance . . coded 2, one person physical assist would be G0110I2 bearing During the 7-day look-back period, the resident required weight- Rationale: assistance with the support of one staff member to use the commode four times. G- October 2018 Page 19

275 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) 5. Miss W . is cognitively and physically impaired . During the 7-day look-back period, she was Staff w ere unable to physically transfer her to toilet during this time. Miss on strict bed rest. W. is incontinent of both bowel and bladder. One staff member was required to provide all several times each day . the care for her elimination and hygiene needs Coding: G0110I1 would be coded 4, total dependence . assist would be G0110I2 . coded 2, one person physical Rationale: Resident did not participate and required one staff person to provide total care for toileting and hygiene each time during the entire 7 -day look- back period. Examples for G0110J, Personal Hygiene 1. The nurse assistant takes Mr. L.’s comb, toothbrush, and toothpaste from the drawer and places them at the bathroom sink. Mr. L. combs his own hair and brushes his own teeth daily. During the 7-day look-back period, he required cueing to brush his teeth on three occasions. Coding: G0110J1 would be coded 1, supervision . . coded 1, setup help only G0110J2 would be Rationale: Staff placed grooming devices at sink for his use, and during the 7-day look- back period staff provided cueing three times. Mrs. J . normally completes all hygiene tasks independently. Three mornings during the 7- day 2. back period, however, she was unable to brush and style her hair because of elbow pain, look- so a staff member did it for her. Coding: G0110J1 would be coded 3, extensive assistance . G0110J2 would be coded 2, one person physical assist . taff member had to complete part of the activity of personal hygiene for Rationale: A s the resident 3 out of 7 days during the look- . T period he assistance, although non- back weight , is considered full staff performance of the personal hygiene sub-task of -bearing brushing and styling her hair. B ecause th is ADL sub -task was completed for the resident 3 times, but not every time during the last 7 days, it qualifies under the second criterion of the extensive assistance definition . Scenario Examples Scenario: 1. The following dressing assistance was provided to Mr. X during the look-back period: Two times, he required guided maneuvering of his arms to don his weight -bearing assistance. Four times, he required the shirt; this assistance was non- staff to assist him to put his shirt on due to pain in his shoulders. During these four times that the staff had to assist Mr. X to put his shirt on, the staff had to physically assist him by lifting each of his arms. This component of the dressing activity occurred six times in the 7 -day look- back period. There were two times where Mr. X weight required non- -bearing assistance and four times where he required weight - bearing assistance, therefore the appropriate code to enter on the MDS is Extensive assistance (3). G- October 2018 Page 20

276 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) Rationale: This ADL activity component occurred six times in the 7- day look- back period. Mr. X required limited assistance two t imes and weight -bearing (extensive) assistance four times. Lifting the resident’s arms is considered weight -bearing assistance. The ADL activity component occurred three or more times at one level, ghest level of dependence -bearing assistance is the hi thus, this weight extensive - identified that occurred three or more times. The scenario is consistent with the ADL Self -Performance coding level definition of Extensive assistance and meets the first Rule of 3. The assessor uses the steps in the Rule of 3 in sequence and stops once one has been identified as applying to the scenario. Therefore the final code that should be entered in Column 1, ADL Self -Performance, G0110G – Dressing is Extensive assistance (3). 2. The following assistance was provided to Mr Scenario: s. C over the last seven pivot Four times, she required verbal cueing for hand placement during stand- days: -bearing assistance to transfers to her wheelchair and three times she required weight help her rise from the wheelchair, steady her and help her turn with her back to the edge of the bed. Once she was at the edge of the bed and put her hand on her transfer bar, she was able to sit. She completed the activity without assistance the 14 back period. The four times that she day look- remaining instances during the 7- required verbal cueing from the staff for hand placement are considered supervision. The three times that the staff had to physically support Mrs. C during a portion of the -bearing assistance. This ADL occurred 21 times over transfer are considered weight the 7 -day look- back period. There were three or more times where supervision was required, and three times where weight -bearing assistance was required; therefore, the appropriate code to enter on the MDS is Extensive assistance (3). back period. Ratio nale: The ADL activity occurred 21 times over the 7- day look- Mrs. C required supervision four times and weight -bearing assistance was provided -day look- back period. The ADL activity also occurred three three times during the 7 or more times at multiple levels (four times with supervision, three times with weight- bearing assistance, and 14 times without assistance). Weight -bearing assistance is also the highest level of dependence identified that occurred three or more times. The first Rule of 3 does not apply because the ADL activity occurred three or more times at multiple levels, not three o r more times at any one level. Because the ADL activity occurred three or more times at multiple levels, the scenario meets the second Rule of 3 and the as sessor will apply the most dependent level that occurred three or more times. Note that this scenario does meet the definition of Extensive assistance as well, since the activity occurred at least three times and there was weight -bearing support hree times. The final code that should be entered in Column 1, ADL Self - provided t Transfer is Extensive assistance (3). Performance, G0110B – Page October 2018 G-21

277 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance ( cont.) Scenario: 3. Mrs. F. was in the nursing home for only one day prior to transferring to another facility. While there, she was unable to complete a component of the eating ADL activity without assistance three times. The following assistance was provided: Twice she requ ired weight -bearing assistance to help lift her fork to her mouth. One time in the evening, the staff fed Mrs. F. because she could not scoop the food on her plate with the fork, nor could she lift the fork to her mouth. The three times that Mrs. F. could not complete the activity, the staff had to physically assist her by either holding her hand as she brought the fork to her mouth, or by actually feeding her. -bearing assistance and one There were two times where the staff provided weight rovided full staff performance. This component of the ADL eating time where they p activity where assistance was required, occurred three times in the look -back period, but not three times at any one level. Based on the third Rule of 3, the final code determination is Exten sive assistance (3). Rationale: Eating occurred three times in the look- back period during the day that Mrs. F was in the nursing home. Mrs. F per formed part of the activity by scooping the food and holding her fork two times, but staff had to assist by l ifting her arm to her mouth resulting in two episode s of weight -bearing assistance. The other time, the t Rule of 3 does not apply be staff had to feed Mrs. F. The firs cause even though the ADL assistance occurred three or more times, it did not occur three times at any one level. The second Rule of 3 does not apply because even though the ADL assistance occurred three or more times it did not occur three or more times at multiple levels. The third Rule of 3 applies since the ADL assistance occurred three ti mes at multiple levels but not three times at any one level. Sub- item “a” under the third Rule of 3 -bearing assistance as states to convert episodes of full staff performance to weight long as the full staff performance episodes did not occur every time the ADL was -day look- back period. Therefore, the one episode of full staff performed in the 7 performance is considered weight -bearing assistance and can be added to the other two episodes of weight -bearing assistance. This now totals three episodes of weigh t- bearing assistance. Therefore, according to the application of the third Rule of 3 and the first two sub -items , “a” and “b,” the correct code to enter in Column 1, ADL Self - Performance, G0110H, Eating is Extensive ass istance (3). Note that none of the ADL -Performance coding level definitions apply directly to this scenario. It is only Self through the application of the third Rule of 3 and the first two sub- items that the facility is able to code this item as extensive assistance. nd Scenario: Mr. N was ad mitted to the facility, but was sent to the hospital on the 2 4. day he was there. The following assistance was provided to Mr. N over the look- back period: Weight -bearing assistance one time to lift Mr. N’s right arm into his shirt sleeves when dressing in the morning on day one, non- weight -bearing assistance one time to button his shirt in the morning on day two, and full staff performance one time on day two to put on his pants on after re sting in bed in the afternoon. Mr. N was on day one when undressing and getting his bed clothes independent in the evening items, the final code on. Based on the application of the third Rule of 3s sub- determination is Limited assis tance (2). Page October 2018 G-22

278 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] cont.) G0110: Activities of Daily Living (ADL) Assistance ( Rationale: There was one episode where Mr. N required full staff performance to put his pants on, one episode of weight -bearing assistance to put his right arm into his shirt weight -bearing assistance to button his shirt. The first sleeve, and one episode of non- Rule of 3 does not apply because even though the ADL assistance occurred three times, it did not occur three times at any one level. The second Rule of 3 does not apply because even though the ADL assistance occurred three times it did not occur three times at multiple levels. The third Rule of 3 applies because the activity occurred three times, and at multiple levels but not three times at any one level. The third Rule of 3, sub- item “a,” instructs providers to convert episodes of full staff performance to weight -bearing episodes and -bearing assistance. Therefore, there are now two weight one non- -bearing episode. The third Rule of 3, sub- item “b,” does not apply weight because even though there are two episodes of weight -bearing assistance, there are not eno ugh weight -bearing episodes to consider it Extensive assistance. There is one weight episode of non- -bearing assista nce that can be accounted for. The third sub- item, “c,” under the third Rule of 3 applies because there is a combination of full staff performance/weight -bearing assistance and/or non -weight -bearing assistance that together total three times (two episodes of weight -bearing assistance and one episode of -bearing assistance). Therefore, the appropriate code is Limited assistance weight non- -Performance, G0110G, ch is the correct code to enter in Column 1, ADL Self (2) whi Dressing. Note that none of the ADL Self -Performance coding level definitions apply directly to this scenario. It is only through the application of the third Rule of 3, working thr ough all of the sub- items, that the facility is able to code this item as Limited assistance. 5. Scenario: During the look- back period, Mr. S was able to toilet independentl y without assistance 18 times. The other two times toileting occurred during the 7- day look- back period, he required the assistance of staff to pull the zipper up on his pants. The assessor This assistance is classified as non- weight -bearing assistance. determined that the appropriate code for G0100I, Toilet use was Code 1, Supervision. - ionale: -weight Rat back period. Non Toilet use occurred 20 times during the look- bearing assistance was provided two times and 18 times the resident used the toilet -Performance coding independently. When the assessor began looking at the ADL Self level definitions, she determined that Independent (i.e., Code 0) cannot be the code entered on the MDS for this ADL activity because in order to be coded as Independent (0), the resident must complete the ADL without any help or oversight from staff every time. Since Mr. S did require assistance to complete the ADL two times, Code 0 does not apply. Code 7, Activity occurred only once or twice, did not apply to this scenario because even though assistance was provided twice during the look- back period, the activity itse lf actually occurred 20 times. The assessor also determined that the assistance provided to the resident does not meet the definition for Limited Assistance (2) because even though the assistance was non -weight -bearing, it was only provided back period, and that the ADL Self twice in the lo ok- -Performance coding level apply directly to this scenario either. The definitions for Codes 1, 3 and 4 did not assessor continued to apply the coding instructions, looking at the Rule of 3. The first Rule of 3 does not apply because even though the ADL activity occurred three or more Page October 2018 G-23

279 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0110: Activities of Daily Living (ADL) Assistance (cont.) times, the non- weight -bearing assistance occurred only twice. The second Rule of 3 does not apply because even though the ADL occurred three or more times , it did not occur three times at multiple levels , and the third Rule of 3 does not apply because the ADL occurred three or more times, at the independent level. Since the third Rule of 3 did not apply, the assessor knew not to appl -items. However, the final y any of the sub instruction to the provider is that when neither the Rule of 3 nor the ADL Self- Performance coding level definitions apply, the appropriate code to enter in Column 1, ADL Self -Performance, is Supervision (1); therefore, in G0110I, Toilet use, the code Supervision (1) was entered. G0120: Bathing Item Rationale DEFINITION Health -related Quality of Life BATHING How the resident takes a full • The resident’s choices regarding his or her bathing shower body bath, or sponge schedule should be accommodated when possible so transfers including bath, in that facility routine does not conflict with resident’s tub or shower. and out of the desired routine. It does not the include or hair. of back washing Planning for Care e care plan should include interventions to address the resident’s unique needs for • Th bathing. These interventions should be periodically evaluated and, if objectives were not met, alternative approaches developed to encourage maintenance of bathing abilitie s. A, Coding Instructions for G0120 Self -Performance Code for the maximum amount of assistance the resident received during the bathing episodes. Code 0, • if the resident required no help from staff. independent: • upervision: Code 1, s if the resident required oversight help only. if the resident is able to perform Code 2, physical help limited to transfer only: • the bathing activity, but required help with the transfer only. G- Page 2018 October 24

280 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0120: Bathing (cont.) • Code 3, p hysical help in part of bathing activity : if the resident required assistance with some aspect of bathing. Code 4, total dependence: if the resident is unable to participate in any of the • bathing activity. • Code 8, ADL a ctivity itself did not occur during entire period: if the activity did not occur or family and/or non-facility staff provided care 100% of the time -day period. for that activity over the entire 7 Coding Instructions for G0120B , Support Provided • Bathing support codes a re as defined ADL Support Provided item ( G0110), Column 2. Coding Tips • Bathing is the only ADL activity for which the ADL Self -Performance codes in Item -Performance) Column 1 (Self -performance et of self do not apply. A unique s , G0110, codes is given that bathing may not occur as frequently as used in the bathing assessment the other ADLs in the 7-day look-back period. • If a nursing home has a policy that all residents are supervised when bathing (i.e., they are never left alone while in the bathroom for a bath or shower, regardless of resident capability ), it is appropri ate to code the resident self -performance as supervision , even if the supervision is precautionary because the resident is still being individually supervised. Support for bathing in this instance would be coded according to whether or not the staff had to actually assist the resident during the bathing activity. Examples 1. Resident received verbal cueing and encouragement to take twice-weekly showers. Once staff walked resident to bathroom, he bathed himself with periodic oversight. : G0120A would be coded 1, supervision . Coding coded 0, no setup or physical help from staff . G0120B would be Rationale: Resident needed only supervision to perform the bathing activity with no setup or physical help from staff. For one bath, the resident received physical help 2. of one person to position self in bathtub. However , because of her fluctuating moods, she received total help for her other bath from one staff member. Coding : G0120A would be coded 4, total dependence . G0120B would be . coded 2, one person physical assist Coding directions for bathing state, “code for most dependent in self- Rationale: performance and support.” Resident’s most dependent episode during the 7-day look- back period was total help with the bathing activity with assist from one staff person. G- October 2018 Page 25

281 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0120: Bathing (cont.) 3. On Monday, one staff member helped transfer resident to tub and washed his legs. On Thursday, the resident had physical help of one person to get into tub but washed himself completely. Coding : G0120A would be coded 3, physical help in part of bathing activity . G0120B would be coded 2, one person physical assist . Rationale: Resident’s most dependent episode during the 7-day look-back period was assistance with part of the bathing activity from one staff person. G0300: Balance During Transitions and Walking Item Rationale DEFINITION Health -related Quality of Life INTERDISCIPLINARY TEAM Individuals with impaired balance and unsteadiness • during transitions and walking Refers to a team that from multiple staff includes are at increased risk for falls; — such as disciplines often are afraid of falling; — nursing, therapy, — may limit their physical and social activity, and physicians, other becoming socially isolated and despondent about advanced practitioners. limitations ; and — can become incr easingly immobile. Planning for Care • Individuals with impaired balance and unsteadiness should be evaluated for the need for rehabilitation or assistive devices — ; supervision or physical assistance for safety; and/or — — environmental modification. Care planning should focus on preventing further decline of function, and/or on return of • function, depending on resident- specific goals. Page 2018 October G- 26

282 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) • Assessment should identify all related risk factors in order to deve lop effective care plans to maintain current abilities, slow decline , and/or promote improvement in the resident’s functional ability . Steps for Assessment 1. Complete this assessment for all residents. Throughout the 7-day look-back period, interdisciplinary team members should carefully 2. observe and document observations of the resident during transitions from sitting to standing, walking, turning, transferring on and off toilet, and transferring from wheelchair to bed and bed to wheelchair (for residents w ho use a wheelchair). ve not systematically documented the resident’s stability in these activities at least 3. If staff ha once during the 7- day look-back period, use the following process to code these items: a. Before beginning the activity, explain what the task is and what you are observing for. b. Have assistive devices the resident normally uses available. Start with the resident sitting up on the edge of his or her bed, in a chair or in a c. wheelchair (if he or she generally uses one). Ask the resident to stand up and stay still for 3-5 seconds. d. Moving from seated to (G 0300A ) should be rated at this time. standing position e. Ask the resident to walk approximately 15 feet using his or her usual assistive device . Walking (G0300B ) should be rated at this time. 0300C ) should be rated at this f. Ask the resident to turn around. Turning around (G time. Ask the resident to walk or wheel from a starting point in his or her room into the g. prepare for toileting as he or she normally does (including taking down pants bathroom, or other clothes; underclothes can be kept on for this observation), and sit on the toilet. Moving on and off toilet (G 0300D ) should be rated at this time. Ask residents who are not ambulatory and who use a wheelchair for mobility h. to transfer to- from a seated position in the wheelchair to a seated position on the bed. Surface- surface transfer should be rated at this time (G 0300E). G- October 2018 Page 27

283 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) Balance During Transitions and Walking Algorithm Did the activity occur? No Code 8 Activity did not occur Yes Yes Did the person require physical assistance? Code 2 Not steady Only able to stabilize No with staff assistance Was the person steady with or without an assistive device Yes that is intentionally for and appropriate for the activity? Code 0 Steady No Code 1 Not Steady but able to stabilize without staff assistance Coding Instructions G0300A, Moving from Seated to Standing Position Code for the least steady episode, using assistive device if applicable. • Code 0, steady at all times: m seated to standing position and from standing to seated If all of the transitions fro — -day look-back period are steady. the 7 position observed during — If resident is stable when standing up using the arms of a chair or an assistive device identified for this purpose (such as a walker, locked wheelchair, or grab bar). — If an assistive device or equipment is used, the resident appropriately plans and integrates the use of the device into the transition activity. If resident appears steady and not at risk of a fall when standing up. — G- Page 2018 October 28

284 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) • Code 1, not steady, but able to stabilize without staff assistance: If any of transitions from seated to standing position — DEFINITION or from standing to seated position during the 7- day the resident is look-back period are not steady, but UNSTEADY able to stabilize without assistance from staff or Residents may appear , a chair or table). object (e.g. a or move unbalanced with sway or with uncoordinated ident is unsteady using an assistive device — If the res or jerking movements that but does not require staff assistance to stabilize. make them unsteady. They — If the resident attempts to stand, sits down, back gaits unsteady exhibit might then is able to stand up and stabilize without large, gaits fast such as with assistance from staff or object. careless movements; gory appear at increased Residents coded in this cate — abnormally slow gaits with small or wide steps; shuffling - risk for falling when standing up. gaits based with halting, • , not steady, only able to stabilize Code 2 steps. tentative with staff assistance: — If any of transitions from seated to standing or from standing to sitting are not steady, . and the resident cannot stabilize without assistance from staff If the resident cannot st and but can transfer unassisted without staff assistance. — — If the resident returned back to a seated position or was unable to move from a seated to standing or from standing to sitting position during the look-back period. — Residents coded in this category appear at high risk f or falling during transitions. — If a lift device (a mechanical device operated by another person) is used because the resident requires staff assistance to stabilize, code as 2. Code 8, activity did not occur: if the resident did not move from seated to • standing position during the 7-day look-back period. Examples for G0300A , Moving from Seated to Standing Position A resident sits up in bed, stands, and begins to sway, but steadies herself and sits down 1. smoothly into her wheelchair. G0300A would be coded 1, not steady, but able to stabilize Coding: without staff assistance . Rationale: Resident was unsteady, but she was able to stabilize herself without assistance from staff. 2. the use of a gait belt and physical assistance in order to stand. A resident requires Coding: G0300A would be coded 2, not steady, only able to stabilize with staff assistance . assistance to stand during the observation period. Resident required staff Rationale: 29 G- Page 2018 October

285 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) 3. A resident stands steadily by pushing himself up using the arms of a chair. Coding: G0300A would be coded 0, steady at all times . Rationale: Even though the resident used the arms of the chair to push himself up, he was steady at all times during the activity. 4. A resident locks his wheelchair and uses the arms of his wheelchair to attempt to stand. On the first attempt, he rises about halfway to a standing position then sits back down. On the second attempt, he is able to stand steadily. coded 1, not steady, but able to stabilize Coding: G0300A would be without staff assistance . Rationale: Even though the second attempt at s tanding was steady, the first attempt suggests he is unsteady and at risk for falling during this transition. Coding Instructions G0300B, Walking (with Assistive Device if Used) Code for the least steady episode, using assistive device if applicable. • Code 0, steady at all times: If during the 7-day look-back period the resident’s walking (with assistive devices if — used) is steady at all times. — If an assistive device or equipment is used, the resident appropriately plans and integrates e and is steady while walking with it. the use of the devic — Residents in this category do not appear at risk for falls. — Residents who walk with an abnormal gait and/or with an assistive device can be steady, and if they are they should be coded in this category. Code 1, not steady, but able to stabilize without staff assistance: • — If during the 7-day look-back period the resident appears unsteady while walking assistance to stabilize. (with assistive devices if used) but does not require staff Residents coded in this category appear at risk for falling while walking. — Code 2, not steady, only able to stabilize with staff assistance: • — If during the 7-day look- back period the resident at any time appeared unsteady and required staff assistance to be stable and safe while walking. — If the resident fell when walking during the look-back period. — Residents coded in this category appear at high risk for falling while walking. Code 8, activity did not occur: • If the resident did not walk during the 7-day look-back period. — G- October 2018 Page 30

286 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) Examples for G0300B , Walking (with Assistive Device if Used) 1. - A resident with a recent stroke walks using a hemi -walker in her right hand because of left sided weakness. Her gait is slow and short- stepped and slightl y unsteady as she walks, she leans to the left and drags her left foot along the ground on most steps. She has not had to steady herself using any furniture or grab bars. G0300B would be coded 1, not steady, but able to stabilize Coding: without staff assistance . Rationale : Resident’s gait is unsteady with or without an assistive device but does not require staff assistance . 2. A resident with Parkinson’s disease ambulates with a walker. His posture is stooped, and he walks slowly with a short-stepped shuffling gait. On some occasions, his gait speeds up, and day it appears he has difficulty slowing down. On multiple occasions during the 7- observation period he has to steady himself using a handrail or a piece of furniture in addition to his walker. Coding: coded 1, not steady, but able to stabilize G0300B would be . assistance without staff Rationale: Resident has an unsteady gait but can stabilize himself using an object such as a handrail or piece of furniture. 3. A resident who had a recent total hip replacement ambulates with a walker. Although she is able to bear weight on her affected side, she is unable to advance her walker safely without staff assistance. Coding: G0300B would be coded 2, not steady, only able to stabilize with . staff assistance assistance to walk steadily and safely at any time requires staff Resident Rationale: during the observation period. -type gait. 4. A resident with multi- infarct dementia walks with a short-stepped, shuf fling Despite t he gait abnormality, she is steady. Coding: G0300B would be coded 0, steady at all times . Rationale: walks steadily (with or without a normal gait and/or the use of an Resident . n period assistive device) at all times during the observatio G- October 2018 Page 31

287 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) Coding Instructions G0300C, Turning Around and Facing the Opposite Direction while Walking Code for the least steady episode, using an assistive device if applicable. Code 0, steady at all times: • If all observed turns to face the opposite direction are steady without assistance of a — staff during the 7-day look-back period. — If the resident is stable making these turns when using an assistive device. — If an assistive device or equipment is used, the resident appropriately plans and integrates the use of the device into the transition activity. — Residents coded as 0 should not appear to be at risk of a fall during a transition. • Code 1, not steady, but able to stabilize without staff assistance: — If any transition that involves turning around to face the opposite direction is not steady, but the resident stabilizes without assistance from a staff. — If the resident is unstable with an assistive device but does not require staff assistance. — s coded in this category appear at increased risk for falling during transitions. Resident Code 2, not steady, only able to stabilize with staff assistance: • If any transition that involves turning around to face the opposite direction is not — steady, and the residen t cannot stabilize without assistance from a staff. — If the resident fell when turning around to face the opposite direction during the look- back period. — Residents coded in this category appear at high risk for falling during transitions. did not occur: • Code 8, activity — If the resident did not turn around to face the opposite direction while walking during the 7 -day look-back period. , Turning Around and Facing the Opposite Examples for G0300C Direction while Walking 1. A resident with Alzheimer’s disease frequently wanders on the hallway. On one occasion, a nursing assistant noted that he was about to fall when turning around. However, by the time she got to him, he had steadied himself on the handrail. G0300C would be coded 1, Not steady, but able to stabilize Coding: . assistance without staff The resident Rationale: was unsteady when turning but able to steady himself on an object, in this instance, a handrail. G- October 2018 Page 32

288 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) 2. -point cane. A nursing A resident with severe arthritis in her knee ambulates with a single assistant observes her lose her balance while turning around to sit in a chair. The nursing assistant is able to get to her before she falls and lower s her gently into the chair. Coding: G0300C would be coded 2, not steady, only able to stabilize with staff assistance . Rationale: The resident was unsteady when turning around and would have fallen assistance. without staff Coding for G0300D, Moving on and off Toilet Code for the least steady episode of moving on and off a toilet or portable commode, using an assistive device if applicable. Include stability while manipulating clothing to allow toileting to occur in this rating. • Code 0, steady at all times: — If all of the observed transitions on and off the toilet during the 7-day look- back period are steady without assistance of a staff . — If the resident is stable when transferring using an assistive device or object identified for this purpose. , grab bar ), the resident appropriately plans and — If an assistive device is used (e.g. integrates the use of the device into the transition activity. Residents coded as 0 should not appear to be at risk of a fall during a transition. — Code 1, not steady, but able to stabilize wit hout staff assistance: • look-back period are not — If any transitions on or off the toilet during the7- day steady, but without assistance from a staff . the resident stabilizes — If resident is unstable with an assistive device but does not require staff assistance. Residents coded in this category appear at increased risk for falling during transitions. — assistance: Code 2, not steady, only able to stabilize with staff • If any transitions on or off the toilet during the 7- day look- back period are not steady, — and the resident cannot stabilize without assistance from a staff . If the resident fell when moving on or off the toilet during the look-back period. — — Residents coded in this category appear at high risk for falling during transitions. — If lift device is used . Code 8, activity did not occur: • If the resident did not transition on and off the toilet during the 7-day look- back — period. G- October 2018 Page 33

289 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) , Moving on and off Toilet Examples for G0300D A resident sits up in bed, stands up, pivots and grabs her walker. She then steadily walks to 1. the bathroom where she pivots, pulls down her underwear, uses the grab bar and smoothly sits on the commode using the grab bar to guide her. After finishing, she stands and pivots using the grab bar and smoothly ambulates out of her room with her walker. Coding: G0300D would be coded 0, steady at all times . This resident’s use of the grab bar was not to prevent a fall after being Rationale: unsteady, but to maintain steadiness during her transitions. The resident was able to smoothly and steadily transfer onto the toilet, using a grab bar. 2. A resident wheels her wheelchair into the bathroom, stands up, begins to lift her dress, sways, and grabs onto the grab bar to steady herself. When she sits down on the toilet, she ly. leans to the side and must push herself away from the towel bar to sit upright steadi Coding: G0300D would be coded 1, not steady, but able to stabilize without staff assistance . The resident was unsteady when disrobing to toilet but was able to steady Rationale: herself with a grab bar. 3. chair into the bathroom, stands, begins to pull his pants down, wheels his wheel A resident sways, and grabs onto the grab bar to steady himself. When he sits down on the toilet, he leans to the side and must push himself away from the sink to sit upright steadily. When finished, he stands, sways, and then is able to steady himself with the grab bar. Coding: G0300D would be coded 1, not steady, but able to stabilize assistance . without staff Rationale: The resident was unsteady when disrobing to toilet but was able to steady himself with a grab bar. Coding Instructions G0300E , Surface-to-Surface Transfer (Transfer between Bed and Chair or Wheelchair) Code for the least steady episode. • Code 0, steady at all times: If all of the observed transfers during the 7- day look -back period are steady without — assistance of a staff . — If the resident is stable when transferring using an assistive device identified for this purpose. — If an assistive device or equipment is used, the resident uses it independently and appropriately plans and integrates the use of the device into the transition activity. should not appear to be at risk of a fall during a transition. coded 0 Residents — G- October 2018 Page 34

290 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) Code 1, not steady, but able to stabilize without staff assistance: • — If any transfers during the look-back period are not steady, but the resident stabilizes without assistance from a staff . — If the resident is unstable with an assistive device but does not require staff assistance. — Residents coded in this category appear at increased risk for falling during transitions. • Code assistance: 2, not steady, only able to stabilize with staff — If any transfers during the 7-day look-back period are not steady, and the resident can only stabilize with assistance from a staff . — resident fell during a surface- If the to-surface transfer during the look -back period. — Residents coded in this category appear at high risk for falling during transitions. — If a lift device (a mechanical device that is completely operated by another person) is used, and this mechanical device is being used because the resident requires staff . ode 2 assistance to stabilize, c • did not occur: 8, activity Code — bed and chair or wheelchair during the 7- day If the resident did not transfer between look-back period. les for G0300E , Surface-to-Surface Transfer (Transfer Between Examp Bed and Chair or Wheelchair) 1. A resident who uses her wheelchair for mobility stands up from the edge of her bed, pivots, and sits in her locked wheelchair in a steady fashion. Coding: G0300E would be coded 0, steady at all times . was steady when transferring from bed to wheelchair . The resident Rationale : 2. A resident who needs assistance ambulating transfers to his chair 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 chair. Coding: G0300E would be coded 2, not steady, only able to stabilize with staff assistance . Rationale : The resident was unsteady when transferring from bed to chair and required staff . assistance to make a steady transfer 3. A resident with an above-the-knee amputation sits on the edge of the bed and, using his locked wheelchair due to unsteadiness and the nightstand for leverage, stands an d transfers to his wheelchair rapidly and almost misses the seat. He is able to steady himself using the nightstand and sit down into the wheelchair without falling to the floor. coded 1, not steady, but able to stabilize G0300E would be Coding: . assistance without staff G- October 2018 Page 35

291 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0300: Balance During Transitions and Walking (cont.) The resident was unsteady when transferring from bed to wheelchair but did Rationale : not require staff assistance to complete the activity. 4. A resident who uses her wheelchair for mobility stands up from the edge of her bed, sways to the right, but then is quickly able to pivot and sits in her locked wheelchair in a steady fashion. lize coded 1, not steady, but able to stabi Coding: G0300E would be assistance without staff . Rationale : The resident was unsteady when transferring from bed to wheelchair but was able to steady herself without staff assistance or an object . Additional Example -E, for G0300A Balance during Transitions and Walking 1. A resident sits up in bed, stands up, pivots and sits in her locked wheelchair. She then wheels her chair to the bathroom where she stands, pivots, lifts gown and smoothly sits on the commode. . times coded 0, steady at all Coding: G0300A, G0300D, G0300E would be : e resident was steady during each activity. Th Rationale G0400: Functional Limitation in Range of Motion Intent: The intent of G0400 is to determine whether DEFINITION functional limitation in range of motion (ROM) interferes with FUNCTIONAL or places him or her at the resident’s activities of daily living IN RANGE LIMITATION taff should refer risk of injury. When completing this item, s back to item G0110 and view the limitation in ROM taking into OF MOTION account activities that the resident is able to perform. move a joint ability to Limited daily interferes with that functioning (particularly with Item Rationale or activities living) of daily -related Quality of Life Health places of the resident at risk injury. Functional impairment could place the resident at risk • of injury or interfere with performance of activities of daily living. Planning for Care Individualized care plans should address possible reversible causes such as de- • conditioning and adverse side eff ects of medications or other treatments. G- October 2018 Page 36

292 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] Limitation in Range of Motion (cont.) G0400: Functional Steps for Assessment 1. Review the medical record for references to functional range of motion limitation during the 7-day look-back period. 2. Talk with staff members who work with the resident as well as family/significant others about any impairment in functional ROM. 3. Coding for functional ROM limitations is a 3 step process: Test the resident’s upper and lower extremity ROM (See #6 below for examples). • If the • resident is noted to have limitation of upper and/or lower extremity ROM, review G0110 and/or directly observe the resident to determine if the limitation interferes with function or places the resident at risk for injury. • Code G0400 A/B as appropriate ba sed on the above assessment. at the shoulder, elbow, wrist, hand, hip, knee, ankle, Assess the resident’s ROM bilaterally 4. foot, and other joints unless contraindicated (e.g., recent fracture, ). or pain joint replacement Staff observations of various activities, including ADLs, may be used to determine if any 5. ROM limitations impact the resident’s functional abilities. 6. Although this item codes for the presence or absence of functional limitation related to ROM; thorough assessment ought to be comprehensive and follow standards of practice for evaluating ROM impairment. Below are some suggested assessment strategies: • 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. Lower Extremity – includes hip, knee, ankle, and foot 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. 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. 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. Alternatively, 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. G- October 2018 Page 37

293 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0400: Functional Limitation in Range of Motion (cont.) Coding Tips • Do not look at limited ROM in isolation. You must determine if the limited ROM impacts functional ability or places the resident at risk for injury. For example, if the resident has an amputation it does not automatically mean that they are limited in function. He/she may not have a particular joint in which certain range of motion can be tested, however, it does not mean that the resident with an amputation has a limitation in completing activities of daily living, nor does it mean that the resident is automatically at many amputees who function extremely well and can complete risk of injury. There are all activities of daily living either with or without the use of prosthetics. If the resident with an amputation does indeed have difficulty completing ADLs and is at risk for injury, the facility should code this item as appropriate. This item is coded in terms of function and risk of injury, not by diagnosis or lack of a limb or digit. Coding Instructions for G0400A, Upper Extremity (Shoulder, Elbow, Wrist, Hand); G0400B, Lower Extremity (Hip, Kn ee, Ankle, Foot) • Code 0, n o impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. • if resident has an upper and/or lower extremity impairment on one side: Code 1, feres with daily functioning or places the resident at risk impairment on one side that inter of injury. impairment on both sides if resident has an upper and/or lower : Code 2, • extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injur y. Examples for G0400A, Upper Extremity (Shoulder, Elbow, Wrist, ; G0400B, Lower Extremity (Hip, Knee, Ankle, Foot) Hand) 1. The resident can perform all arm, hand, and leg motions on the right side, with smooth coordinated movements. She is able to perform grooming activities (e.g. brush teeth, comb her hair) with her right upper extremity, and is also able to pivot to her wheelchair with the assist of one person. She is , however, unable to voluntarily move her left side (limited arm, hand and leg motion) as she has a flaccid left hemiparesis from a prior stroke. Coding: G0400A would be coded 1, upper extremity impairment on one side . coded 1, lower extremity impairment on one side G0400B would be . : Rationale Impairment due to left hemiparesis affects both upper and lower extremities on one side. Even though this resident has limited ROM that impairs function on the left side, as indicated above, the resident can perform ROM fully on the right side. Even though there is impairment on one side, the facility should always attempt to provide the resident with assistive devices or physical assistance that allows for the resident to be as independent as possible. G- October 2018 Page 38

294 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0400: Functional Limitation in Range of Motion (cont.) 2. The resident had shoulder surgery and can’t brush her hair or raise her right arm above her The resident has no impairment on the lower extremities. head. Coding: G0400A would be coded 1, upper extremity impairment on one side . . coded 0, no impairment G0400B would be : Impairment due to shoulder surgery affects only one side of her upper Rationale extremities. 3. The resident has a diagnosis of Parkinson’s and ambulates with a shuffling gate. The resident has had 3 falls in the past quarter and often forgets his walker which he needs to ambulate. He has tremors of both upper extremities that make it very difficult to feed himself, brush his teeth or write. coded 2, upper extremity impairment on both : G0400A would be Coding sides . G0400B would be coded 2, lower extremity impairment on both sides . Ra tionale: Impairment due to Parkinson’s disease affects the resident at the upper and lower extremities on both sides. Mobility Devices G0600: Item Rationale Health -related Quality of Life • Maintaining independence is important to an individual’s feelings of autonomy and self- worth. The use of devices may assist the resident in maintaining that independence. Planning for Care ident ability to move about his or her room, unit or nursing home may be directly Res • related to the use of devices. It is critical that nursing home staff assure that the resident’s ized by making available mobility devices on a daily basis, if independence is optim . needed G- October 2018 Page 39

295 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0600: Mobility Devices (cont.) Steps for Assessment the medical record for references to locomotion during the 7-day look-back period. 1. Review with staff members who work with the resident as well as family/significant others Talk 2. about devices the resident used for mobility during the look-back period. Observe the resident during locomotion. 3. Coding Instructions the resident normally uses for locomotion (in room and in Record the type(s) of mobility devices facility). Check all that apply: if the resident used a cane or crutch, including single • Check G0600A, c ane/ crutch: prong, tripod, quad cane, etc. • Check G0600B, walker: if the resident used a walker or hemi -walker, including an enclosed frame-wheeled walker with/without a posterior seat and lap cushion. Also check this item if the resident walks while pushing a wheelchair for support. if the reside nt normally sits wheelchair (manual or electric) : • Check G0600C, in wheelchair when moving about. Include hand-propelled, motorized, or pushed by another person. Do not include geri-chairs, reclining chairs with wheels, positioning chairs, scooters, and other types of specialty chairs. Check G0600D, l im if the resident used an a rtificial limb to replace a b prosthesis: • missing extremity . • Check G0600Z, n one of the above: if the resident used none of the mobility devices listed in G0600 or locomotion did not occur during the look-back period. Examples 1. The r esident uses a quad cane daily to walk in the room and on the unit. The resident uses a standard push wheel chair that she self -propels when leaving the unit due to her issues with endurance. G0600A, use of cane/crutch , and G0600C, wheelchair, would be Coding: checked. : Th Rationale e resident uses a quad cane in her room and on the unit and a wheelchair off the unit. 2. The resident has an artificial leg that is applied each morning and removed each evening. Once the prosthesis is applied the resident is able to ambulate independently. Coding: G 0600D, limb prosthesis , would be checked. The resident use : Rationale leg prosthesis for ambulating. s a G- October 2018 Page 40

296 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0900: Functional Rehabilitation Potential Complete only on OBRA Admission Assessment (A0310A = 1) Rationale Item Health -related Quality of Life • Attaining and maintaining independence is important to an individual’s feelings of autonomy and self- worth. • Independence is also important to health status, as decline in function can trigger all of the complications of immobility, depression, and social isolation. Planning for Care • Beliefs held by the resident and staff that the resident has the capacity for greater independence and involvement in self- care in at least some ADL areas may be important in setting goals. to assist clues Even if highly independent in an activity, the resident or staff may believe the resident • can gain more independence (e.g., walk longer distances, shower independently). • the Disagreement between staff beliefs and resident beliefs should be explored by interdisciplinary team. Steps for Assessment: Interview Instructions for G0900A, Resident Believes He or She Is Capable of Increased Independence in at Least Some ADLs Ask if the resident thinks he or she could be more self- sufficient given more time. 1. Listen to and record what the resident believes, even if it appears unrealistic. 2. • It is sometimes helpful to have a conversation with the resident that helps him/her break down this question. For example, you might ask the resident what types of things staff assist him with and how much of those activities the staff do for the resident. Then ask the resident, “Do you think that you could get to a point where you do more or all of the activity yourself?” Coding Instructions for G0900A , Resident Believes He or She Is Capable of Increased Independence in at Least Some ADLs if the resident indicate • Code 0, n o: s that he or she believes he or she will probably stay with continue the same and his or her current needs for assistance. G- October 2018 Page 41

297 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [G] G0900: Functional Rehabilitation Potential (cont.) Code 1, y s that he or she thinks he or she can improve. Code • if the resident indicate es: even if the resident’s expectation appears unrealistic. if the resident cannot indicate any beliefs about his • Code 9, u nable to determine: or her functional rehabilitation potential. for G0900A , Resident Believes He or She Is Capable of Example Increased Independence in at Least Some ADLs receives limited physical assistance in locomotion for 1. Mr. N . is cognitively impaired and safety purposes. However, he believes he is capable of walking alone and often gets up and walk s by himself when staff are not looking. Coding: G0900A would be coded 1, yes . Rationale . The resident believes he is capable of increased independence : , Direct Care Staff Believe Resident Steps for Assessment for G0900B Is Capable of Increased Independence in at Least Some ADLs Discuss in interdisciplinary team meeting. 1. 2. Ask staff who routinely care for or work with the resident if they think he or she is capable of greater independence in at least some ADLs. , Direc t Care Staff Believe Resident Is Coding Instructions for G0900B Capable of Increased Independence in at Least Some ADLs • Code 0, n o: if staff believe the resident probably will stay the same and continue with current needs for assistance. Also code 0 if staff believe the resident is likely to experience a decrease in his or her capacity for ADL care performance. • if staff believe the resident can gain greater independence i Code 1, y n ADLs or if es: staff indicate they are not sure about the potential for improvement, because that indicates some potential for improvement. Example for G0900B , Direct Care Staff Believe Resident Is Capable of Increased Independence in at Least Some ADLs 1. The nurse assistant who totally feeds Mrs. W. has noticed in the past week that Mrs. W. has made several attempts to pick up finger foods. She believes Mrs. W. could become more independent in eating if she received close supervision and cueing in a small group for restorative care in eating. G0900B would be . Coding: coded 1, yes Based upon observation of the resident, the nurse assistant believes Mrs. W. Rationale: is capable of increased independence. G- October 2018 Page 42

298 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 SECTION GG: FUNCTIONAL ABILITIES AND GOALS Intent: includes items about functional abilities and goals. It includes items This section focused on prior function, admission performance, discharge goals, and discharge performance. the need for assistance -care and when performing self Functional status is assessed based on mobility activities. GG0100. Prior Functioning: Everyday Activities Item Rationale Knowledge of the resident’s functioning prior to the current illness, exacerbation, or • injury may inform treatment goals. Steps for Assessment 1. Ask the resident or his or her family about, or review the resident’s medical records veryday activities. describing, the resident’s prior functioning with e Coding Inst ruct ions • Code 3, Independent: if the resident completed the activities by himself or herself, with or without an assistive device, with no assistance from a helper. Code 2, Needed Some Help: if the resident needed partial assistance from another • person to complete the activities. if the helper completed the activities for the resident, or the • Code 1, Dependent: assistance of two or more helpers was required for the resident to complete the activities. esident’s usual ability prior to the current illness, if the r Code 8, Unknown: • exacerbation, or injury is unknown. • if the activities were not applicable to the resident prior to Code 9, Not Applicable: the current illness, exacerbation, or injury. Page GG-1 October 20 18

299 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0100. Prior Functioning: Everyday Activities (cont.) Coding Tips Record the resident’s usual ability to perform self-care, indoor mobility (ambulation), • stairs, and functional cognition prior to the current illness, exacerbation, or injury. • If no information about the resident’s ability is available after attempts to interview the resident or his or her family and after reviewing the resident’s medical record, code as 8, Unknown. Examples for Coding Prior Functioning: Everyday Activities 1. Self -Care: Ms. R was admitted to an acute care facility after sustaining a right hip fracture and subsequently admitted to the SNF for rehabilitation. Prior to the hip fracture, Ms. R was independent in eating, bathing, dressing, and using the toilet. Ms. R used a raised toilet seat because of arthritis in both knee joints. Both she and her family indicated that there were no safety concerns when she performed these everyday activities in her home. GG0100A would be coded 3, Independent. Coding: Prior to her hip fracture, the resident completed the self- Rationale: care tasks of eating, bathing, dressing, and using the toilet safely without any assistance from a helper. The resident may use an assistive device, such as a raised toilet seat, and still be coded as independent. Self 2. Mr. T was admitted to an acute care facility after sustaining a stroke and -Care: subsequently admitted to the SNF for rehabilitation. Prior to the stroke, Mr. T was independent in eating and using the toilet; however, Mr. T required assistance for bathing and putting on and taking off his shoes and socks. The assistance needed was due to severe arthritic lumbar pain upon bending, which limited his ability to access his feet. . 2, Needed Some Help Coding: GG0100A would be coded Mr. T needed partial assistance from a helper to complete the activities of Rationale: bathing and dressing. While Mr. T did not need help for all self- care activities, he did care. need some help. Code 2 is used to indicate that Mr. T needed some help for self- Mr. R was diagnosed with a progressive neurologic condition five years ago. He 3. Self -Care: lives in a long-term nursing facility and was recently hospitalized for surgery and has now been admitted to the SNF for skilled services. According to Mr. R’s wife, prior to the surgery, Mr. R required complete assistance with self-care activities, including eating, bathing, dressing, and using the toilet. Coding: GG0100A would be coded 1, Dependent. Mr. R’s wife has reported that Mr. R was completely dependent in self Rationale: -care activities that included eating, bathing, dressing, and using the toilet. Code 1, Dependent, is appropriate based upon this information. Page GG-2 October 20 18

300 CMS’s CH 3: MDS Items [ GG] Manual RAI Version 3.0 GG0100. Prior Functioning: Everyday Activi ties (cont.) 4. Mr. F was admitted with a diagnosis of stroke and a severe communication -Care: Self disorder and is unable to communicate with staff using alternative communication devices. Mr. F had been living alone prior to admission. The staff has not bee n successful in -care abilities are unknown. contacting either Mr. F’s family or his friends. Mr. F’s prior self Coding: 8, Unknown. GG0100A would be coded Attempts to seek information regarding Mr. F’s prior functioning were Rationale: made; however, no information was available. This item is coded 8, Unknown. 5. Mr. C was admitted to an acute care hospital after Indoor Mobility (Ambulation): experiencing a stroke. Pri or to admission, he used a cane to walk from room to room. In the morning, Mr. C’ s wife would provide steadying assistance to Mr. C when he walked from room to room because of joint stiffness and severe arthritis pain. Occasionally, Mr. C required steadyi ng assistance during the day when walking from room to room. Coding: GG01 00B would be coded 2, Needed Some Help. The resident needed some assistance (steadying assistance) from his wife to Rationale: complete the activity of walking in the home. 6. Indoor Mobility (Ambulation): Approximately three months ago, Mr. K had a cardiac event that resulted in anoxia, and subsequently a swallowing disorder. Mr. K has been living at home with his wife and developed aspiration pneumonia. After this most recent hospitalization, he was admitted to the SNF for aspiration pneumonia and severe deconditioning. Prior to the most recent acute care hospitalization, Mr. K needed some assistance when walking. Coding: GG0100B would be coded 2, Needed Some Help. Rationale: While the resident experienced a cardiac event three months ago, he recently had an exacerbation of a prior condition that required care in an acute care based on the time hospital and skilled nursing facility. The resident’s prior functioning is ely before his most recent condition exacerbation that required acute care. immediat 7. Indoor Mobility (Ambulation): Mrs. L had a stroke one year ago that resulted in her using a -mobilize, as she was unable to walk. Mrs. L subsequently had a second wheelchair to self stroke and was transferred from an acute care unit to the SNF for skilled services. GG0100B would be coded 9, Not Applicable. Coding: The resident did not ambulate immediately prior to the current illness, Rationale: injury, or exacerbation (the second stroke). 3 October 2018 Page GG-

301 CMS’s CH 3: MDS Items [ GG] Manual RAI Version 3.0 GG0100. Prior Functioning: Everyday Activities (cont.) 8. Prior to admission to the hospital for bilateral knee surgery, followed by his recent : Stairs admission to the SNF for rehabilitation, Mr. V experienced severe knee pain upon ascending and particularly descending his internal and external stairs at home. Mr. V required event his left knee would assistance from his wife when using the stairs to steady him in the buckle. Mr. V’s wife was interviewed about her husband’s functioning prior to admission, and the therapist noted Mr. V’s prior functional level information in his medical record. Coding: GG0100C would be coded 2, Needed Some Help. Rationale: Prior to admission, Mr. V required some help in order to manage internal and external stairs. Mrs. E lived alone prior to her hospitalization for sepsis and has early stage multiple Stairs: 9. rehabilitation as a result of sclerosis. She has now been admitted to a SNF for deconditioning. Mrs. E reports that she used a straight cane to ascend and descend her indoor stairs at home and small staircases within her community. Mrs. E reports that she did not require any human assistance with the act ivity of using stairs prior to her admission. would be coded 3, Independent. Coding: GG0100C Rationale: Mrs. E reported that prior to admission, she was independent in using her internal stairs and the use of small staircases in her community. Mr. P has expressive aphasia and difficulty communicating. SNF staff have not Stairs: 10. received any response to their phone messages to Mr. P’s family members requesting a return call. Mr. P has not received any visitors since his admission. The medical record from prior facility does not indicate Mr. P’s prior functioning. There is no information to code his item GG0100C, but there have been attempts at seeking this information. Coding: GG0100C would be coded 8, Unknown. Rationale: Attempts were made to seek informatio n regarding Mr. P’s prior functioning; however, no information was available. 11. Mr. K has mild dementia and recently sustained a fall resulting in Functional Cognition: complex multiple fractures requiring multiple surgeries. Mr. K has been admitted to the SNF for rehabilitation. Mr. K’s caregiver reports that when living at home, Mr. K needed reminders t o take his medications on time, manage his money, and plan tasks, especially when he was fatigued. Coding: 2, Needed Some Help. GG0100D would be coded Rationale: Mr. K required some help to recall, perform, and plan regular daily activities as a result of cognitive impairment. 4 October 2018 Page GG-

302 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 GG0100. Prior Functioning: Everyday Activities (cont.) Ms. L recently sustained a brain injury from a fall at home. Prior to Functional Cognition: 12. her recent hospitalization, she had been living in an apartment by herself. Ms. L’s cognition is currently impaired. Ms. L’s cousin, who had visited her frequently prior to her recent hospitalization, indicated that Ms. L did not require any help with taking her prescribed medications, planning her daily activities, and managing money when shopping. Coding: 3, Independent. GG0100D would be coded Ms. L’s cousin, who frequently visited Ms. L prior to her sustaining a brain Rationale: injury, reported that Ms. L was independent in taking her prescribed medications, planning her daily activities, and managing money when shopping, indicating her independence in using memory and problem- solving skills. 13. Functional Cognition: Mrs. R had a stroke, resulting in a severe communication disorder. Her family members have not returned phone calls requesting information about Mrs. R’s prior functional status, and her medical records do not include information about her functional cognition prior to the str oke. GG0100D would be coded 8, Unknown. Coding: Rationale: Attempts to seek information regarding Mrs. R’s prior functioning were made; however, no information was available. GG0110. Prior Device Use Item Rationale and aids immediately prior to the • Knowledge of the resident’s routine use of devices current illness, exacerbation, or injury may inform treatment goals. Steps for Assessment Ask the resident or his or her family or review the resident’s medical records to determine 1. the resident’s use of prior devices and aids. Page GG-5 October 20 18

303 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0110. Prior Device Use (cont.) Coding Instructions • Check all devices that apply. • if the resident did not use any of the listed devices or Check Z, None of the above: aids immediately prior to the current illness, exacerbation, or injury. Coding Tips • For GG0110D, Prior Device Use - Walker: “Walker” refers to all types of walkers (for example, pickup walkers, hemi-walkers, rolling walkers, and platform walkers). GG0110C, Mechanical lift, includes sit- • style lifts. to-stand, stand assist, and full-body- Example for Coding Prior Device Use Mrs. M is a bilateral lower extremity amputee and has multiple diagnoses, including diabetes, obesity, and peripheral vascular disease. She is unable to walk and did not walk prior to the current episode of care, which started because of a pressure ulcer and respiratory infection. She uses a motorized wheelchair to mobilize. Coding: GG0110B would be checked. Mrs. M used a motorized wheelchair prior to the current illness/injury. Rationale: Page GG-6 October 20 18

304 CMS’s Manual CH 3: MDS Items [ GG] Version 3.0 RAI GG0130: Self- (Start Care (3 mission -day assessment period) Ad of Medicare Part A Stay) Page GG-7 18 20 October

305 CMS’s Version 3.0 Manual CH 3: MDS Items [ GG] RAI -day assessment period) Care (3 GG0130: Self- Discharge (End of Medicare Part A Stay) Rat Item iona le -care limitations on During a Medicare Part A SNF stay, residents may have self • admission. In addition, residents may be at risk of further functional decline during their . stay in the SNF Page GG-8 October 20 18

306 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 GG0130: Self- -day assessment period) Care (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Steps for Assessment 1. A ssess the resident ’s self -care performance based on direct observation, as well as the resident’s self -report and reports from qualified clinicians , care staff , or family documented record during the CMS anticipates that . assessment period three-day in the resident’s medical an interdisciplinary team of qualified clinicians is involved in assessing the resident during For Section GG, the admission assessment period is the first the three-day assessment period. three days of the Part A stay st arting with th e date in A2400B, the Start of M ost R ecent Medicare S tay . On admission, these items are completed only when A0310B = 01 (5- Day PPS assessment). Resident s should be allowed to perform activities as independently as possible, as long as 2. they are safe. DEFINITION ” is 3. For the purposes of completing Section GG, a “ helper defined as facility staff who are direct employees and USUAL PERFORMANCE facility -contracted employees (e.g. , rehabilitation staff, A resident’s functional status “helper” does not include nursing agency staff). Thus, can be impacted by the individuals hired, compensated or not, by individuals outside environment or situations ’ s management and administration such as of the facility ountered at the facility. enc certified nursing assistant students, etc. hospice staff, nursing/ ent’s Observing the resid Therefore, when helper assistance is required because a interactions with others in resident’s performance is unsafe or of poor quality, consider different locations and circumstances is important ing according to the only facility staff when scor amount of for a comprehensive assistance provided. understanding of the Activities may be completed with or without assistive 4. If status. s functional resident’ device(s ). Use of assistive device(s) to complete an activity the resident’s functional should not affect coding of the activity. status varies, record the ’s usual ability to resident The admission functional assessment, when possible, should 5. perform each activity. Do not be conducted prior to the person benefitting from treatment ’s best record the resident interventions in order to determine a true baseline functional performance and do not status on admission. If treatment has started, for example, on record the resident ’s worst the day of admission, a baseline functional status assessment performance, but rather can still be conducted. Treatment should not be withheld in record the resident ’s usual . performance order to conduct the functional assessment. , and State policies and procedures Refer to facility, Federal 6. QUALIFIED CLINICIAN to determine which staff members may complete an Healthcare professionals assessment. Resident assessments are to b e done in practicin g within their scope compliance with facility, Federal, and State requirements. of practice and consistent with Federal, State, and local law and regulations. October 20 Page GG-9 18

307 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Care (3 GG0130: Self- -day assessment period) (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) nstruct ions Admission or Discharge Performance Coding I • When coding the resident’s usual performance and discharge goal(s), use the six-point scale, or use one of the four “activity was not attempted” codes to specify the reason why an activity was not attempted. no • Code 06, Independent : if the resident completes the activity by him/herself with assist ance from a helper. Code 05, Setup or clean- up assistance: • if the helper SETS UP or CLEANS UP; resident completes activ ity. Helper assists only prior to or following the activity, but not during the activity. For exa mple, the resident requires assistance cutting up food or opening container, or requires setup of hygiene item(s) or assisti ve device(s). • Code 04, Supervision or touching assistance: if the helper provides VERBAL CUES or TOUCHING/ STEADYING assistance a s resident completes activity. Assistance may be provided throughout the activity or intermittently. For example, the resident requires verbal cueing, coaxing, or general supervision for safety to complete activity; or resident may require only incidental help such as contact guard or steadying assist during the activity. • if the helper does LESS THAN HALF the rate assistance: ial/ mode Code 03, Part effort. Helper lifts, holds, or supports trunk or limbs, but provides less than hal f the effort. Code 02, Subs tant ial/ maxi mal assistance: if the helpe r does MORE THAN HALF • the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. • Code 01, Dependent : if the helper does ALL of the ef fort. Resident does none of the effort to complete the activity ; or the assistance of two or more helpers is required for the resident to complete the activity. • refused to complete t Code 07, ivity. he act if the resident ed: Resident r efus did not Code 09, Not applicable: if the activity was not attempted and the resident • ity prior to the current illness, exacerbation, or injury. perform this activ • Code 10, Not attempted due to environmental limitations: if the resident did not attempt this activity due to environmental limitations. Examples include lack of equipment and weather constraints. : tion or safety concerns ical condi Code 88, Not attempted due to med if the • ns. condition or safety concer mpted due to medical activity was not atte 10 October 20 18 Page GG-

308 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) Care (3 GG0130: Self- Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Assessment Period -required -Day PPS assessment (A0310B = 01) is the first Medicare • Admission: The 5 assessment to be completed when the resident is admitted for a SNF Part A . stay o For the 5 - Day PPS assessment, code the resident’ s functional status based on a ’s resident clinical assessment of the resident’s performance that occurs soon after the . This functional assessment must be completed within the first three days admission (3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start , of Most Recent Medicare Stay and the following two days, ending at 11:59 PM on . day 3 The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the resident’s assessment should occur, when The status prior to any benefit from interventions. possible, prior to the resident benefitting from treatment interventions in order to the resident’s true admission baseline status . Even if treatment started on determine essment can still be conducted. the day of admission, a baseline functional status ass Treatment should not be withheld in order to conduct the functional assessment. Discharge: The Part A PPS Discharge assessment is required to be completed when the • resident’s Medicare Part A Stay ends (as documented in A2400C, End of Most Recent Medicare Stay), either as a standalone assessment when the resident’s Medicare Part A stay ends, but the resident remains in the facility; or may be combined with an OBRA ne day before the resident’s Discharge if the Medicare Part A stay ends on the day of, or o Discharge Date (A2000). Please see Chapter 2 and Section A of the RAI Manual for additional details regarding the Part A PPS Discharge assessment. o For the Discharge assessment (i.e., standalone Part A PPS or combined OBRA/Part A PPS), code the residen t’s discharge functional status, based on a clinical assessment esident of the r ’s of the resident’s performance that occurs as close to the time . Th discharge from Medicare Part A as possible is functional assessment must be completed within the last three calendar days of the resident ’s Medicare Part A stay, prior to from Medicare Part A and the two days which includes the day of discharge the day of discharge from Medicare Part A . Coding Tips: Admission o r Discharge Performance General Coding Tips When reviewing the medical record, • interviewing staff , and observing the resident , be familiar with the definition for each activity (e.g., eating , oral hygiene) . For example, (item GG0130A) when assessing Eating , determine the type and amount of assistance and/or liquid once and/or liquid required to bring food to the mouth and swallow food the meal is placed before the resident. 11 October 20 18 Page GG-

309 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual GG0130: Self- Care (3 -day assessment period) Admission/Discharge (Start/End of Me dicare Part A Stay) (cont.) • Residents with cognitive impairments/limitations may need physical and/or verbal need for assistance assistance when completing an activity. Code based on the resident’s to perform the activity safely (for example, choking risk due to rate of eating, amount of food placed into mouth, risk of falling). • If the resident does not attempt the activity and a helper does not complete the activity for the resident during the entire assessment period , code the reason the activity w as not attempted. For example, code as 07 if the resident refused to attempt the activity ; code as (the activity did not occur at the time of 09 if the resident activity is not applicable for the the assessment and prior to the current illness, injury, or exacerbation); code as 10 if the or code resident was not able to attempt the activity due to environmental limitations; as due to medical condition or safety 88 if the resident was not able to attempt the activity concerns. • An activity can be completed independently with or without devices. If the resident uses adaptive equipment and uses the device independently when performing an activity, enter code 06, Independent. If two or more helper • s are required to assist the resident to complet e the activity, code as 01, Dependent. performance of an activity, ask • To clarify your own understanding of the resident’s staff about the resident , beginning with the general and the care probing questions to proceeding to the more specific. See examples of probing questions at the end of this section. • A dash (“ -”) indicates “No information.” CMS expects dash use to be a rare occurrence. • Documentation in the medical record is used to support assessment coding of Section GG. D ata entered should be consistent with the clinical assessment documentation in the resident’s medical record . This assessment can be conducted by appropriate healthcare personnel as defined by facility policy and in accordance with S tate and F ederal regulations. ance Tips for Coding the Resident’s Usual Perform When coding the resident’s usual performance, “effort” refers to the type and amount of • assistance a helper provides in order for the activity to be completed. The six-point rating scale definitions include the following types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance. 12 October 20 18 Page GG-

310 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0130: Self- Care (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Do not record the resident’s best performance, and do not record the resident’s worst • performance, but rather record the resident’s usual performance during the assessment period. Code based on the resident’s performance. Do not record the staff’s assessment of the • resident’s potential capability to perform the activity. • If the reside nt performs the activity more than once during the assessment period and the resident’s performance varies, coding in Section GG should be based on the resident’s “usual performance,” which is identified as the resident’s usual activity/performance for any of the Self-Care or Mobility activities, not the most independent or dependent performance the assessment period. Therefore, if the resident’s Self-Care performance varies during over the assessment period, report the resident’s usual performance, the resident’s most not not independent performance and the resident’s most dependent performance. A provider may need to use the entire three-day assessment period to obtain the resident’s usual performance. Coding Tips for GG0130A, Eating Resident receives t • ube feedings or total parenteral nutrition (TPN): solely o If the resident does not eat or drink by mouth and relies on nutrition and -onset) medical new (recent liquids through tube feedings or TPN because of a code GG0130A as 88, Not attempted due to medical condition or safety condition, concerns. Assistance with tube feedings or TPN is not considered when coding Eating. o If the resident does not eat or drink by mouth at the time of the assessment, and the prior to the current illness, injury, or resident did not eat or drink by mouth exacerbation, code GG0130A as 09, Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Assistance with tube feedings or TPN is not considered when coding Eating. on obtaining nutrition partially o If the resident eats and drinks by mouth, and relies and liquids via tube feedings or TPN, code Eating based on the amount of assistance the resident requires to eat and drink by mouth. Assistance with tube feedings or TPN is not considered when coding Eating. • If the resident eats finger foods using his or her hands, then code Eating based upon the amount of assistance provided. If the resident eats finger foods with his or her hands independently, for example, the resident would be coded as 06, Independent. 13 October 20 18 Page GG-

311 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0130: Self- Care (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Examples for Coding Admission Performance or Discharge Performance Note: The following are coding examples for each S elf -C are item. Some examples describe a single observation of the person completing the activity; other examples describe a summary of several observations of the resident completing an activity across different times of the day and different days. Examples for GG0130A, Eating 1. Eating: Ms. S has m ultiple s clerosis , affecting her endurance and strength. Ms. S prefers to feed herself as much as she is capable. During all meals, a fter eating three -fourths of t he meal becomes extremely fatigued and requests assistance from by herself , Ms. S usually the certified nursing assistant to feed her the remainder of the meal. Coding: GG0130A would be coded 03, Partial/moderate assistance. provides less than half the effort for the The certified nursing assistant Rationale: resident to complete the activity of eating . for all meals 2. Mr. M has upper extremity weakness and fine motor impairments. The occupational Eating: therapist places an adaptive device onto Mr. M’s hand that supports the eating utensil within his hand. At the start of each meal Mr. M can bring food and liquids to his mouth. Mr. M then tires and the certified nursing assistant feeds him more than half of each meal. Coding: GG0130A would be coded 02, Substa ntial/maximal assistance. Rationale: The helper provides more than half the effort for the resident to complete at each meal the activity of eating . 3. eats all meals without any physical assistance or supervision from a helper. Mr. A Eating: He has a gastro stomy tube (G-tube), but it is no longer used , and it will be removed later today. Coding: GG0130A would be coded 06, Independent. The resident can independently complete the activity without any assistance Rationale: from a helper for this a In this scenario, the presence of a G-tube does not affect ctivity. the eating score. 4. Eating: The dietary aide opens all of Mr. S’s cartons and containers on his food tray before leaving the room. There are no safety concerns regarding Mr. S’s ability to eat. Mr. S eats the food himself, bringing the food to his mouth using appropriate utensils and swallowing the food safely. -up assistance. Coding: GG0130A would be coded 05, Setup or clean The helper provided setup assistance prior to the eating activity. Rationale: 14 October 20 18 Page GG-

312 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0130: Self- Care (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Eating: 5. Mrs. H does not have any food consistency restrictions, but often needs to swallow 2 or 3 times so that the food clears her throat due to difficulty with pharyngeal peristalsis. She requires verbal cues from the certified nursing assistant to use the compensatory strategy of extra swallows to clear the food. Coding: GG0130A would be coded 04, Supervision or touching assistance . Rationale: Mrs. H swallows all types of food consistencies and requires verbal cueing (supervision) from the helper. 6. Eating: Mrs. V has had difficulty seeing on her left side since her stroke. During meals, the certified nursing assistant has to remind he r to scan her entire meal tray to ensure she has seen all the food. Coding: GG0130A would be coded 04, Supervision or touching assistance . Mrs. V ing assistance during meals as Rationale: The helper provides verbal cue pervision, such as reminders, may be provided . Su of eating completes the activity throughout the activity or intermittently. 7. Eating: Mrs. N is impulsive. While she eats, the certified nursing assistant provides verbal and tactile cueing so that Mrs. N does not lift her fork to her mouth until she has swallowed the food in her mouth. Coding: GG0130A would be coded 04, Supervision or touching assistance . Rationale: The resident requires supervision and touching assistance in order to eat safely. . He receives Eating: Mr. R is unable to eat by mouth since he had a stroke one week ago 8. -tube), which is administered by nurses. nutrition through a gastrostomy tube (G GG0130A would be coded 88, Not attempted due to medical condition or Coding: . safety con cerns Rationale: The resident does not eat or drink by mouth at this time due to his recent - onset stroke. This item includes eating and drinking by mouth only. Since eating and drinking did not occur due to his recent -onset medical condition, the activity is coded as 88, Not attempted due to medical condition and safety concerns . Assistance with G -tube feedings is not considered when coding this item. Mr. F is fed all meals by the certified nursing assistant, because Mr. F has severe 9. Eating: arm weakness and he is unable to assist. Coding: would be coded 01, Dependent. GG0130A Rationale: The helper does all of the effort for each meal. The resident does not o complete the eating activity. contribute any effort t 15 October 2018 Page GG-

313 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0130: Self- Care (3 -day assessment period ) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) and handed s himself more feed 10. Eating : Mr. J had a stroke that affects his left side. He is left- than half of his meal requests assistance from the certified nursing s, but tires easily. Mr. J assistant with the remainder of his meal s. Coding: GG0130A would be coded 03, Partial/moderate assistance. Rationale: The certified nursing assistant provides less than half the effort for the resident to complete the activity of eating. 11. s. M has osteoporosis, which contributed to the fracture of her right wrist and hip Eating: Mr during a recent fall. She is right-handed. Mrs. M starts eating on her own, but she does not have the coordination in her left hand to manage the eating utensils to feed herself without great effort. Mrs. M tires easily and cannot complete eating the meal. The certified nursing assistant feeds her more than half of the meal. GG0130A would be coded 02, Substantial/maximal assistance. Coding: Rationale: The helper provides more than half the effort for the resident to complete the activity of eating. Coding Tip for GG0130B, Oral hygiene • If a resident does not perform oral hygiene during therapy, determine the resident’s abilities based on performance on the nursing care unit. , Oral hygiene Examples for GG0130B 1. Oral hygiene: In the morning and at night, Mrs. F brushes her teeth while sitting on the side of the bed. Each time, the certified nursing assistant gathers her toothbrush, toothpaste, water, and an empty cup and puts them on the bedside table for her before leaving the room. Once Mrs. F is finished brushing her teeth, which she does without any help, the certified nursing assistant returns to gather her items and dispose of the waste. Coding: GG0130B would be coded 05, Setup or c lean -up a ssistance . up assistance. The resident brushes her Rationale: The helper provides setup and clean- teeth without any help. 2. Oral hygiene: Before bedtime, the nurse provides steadying assistance to Mr. S as he walks to the bathroom. The nur se applies toothpaste onto Mr. S’s toothbrush. Mr. S then brushes his teeth at the sink in the bathroom without physical assistance or supervision. Once Mr. S is done brushing his teeth and washing his hands and face, the nurse returns and provides steadyi ng assistance as the resident walks back to his bed. Coding: GG0130B would be coded 05, Setup or c lean -up a ssistance . Rationale : The helper provides setup assistance (putting toothpaste on the toothbrush) his teeth. Do not consider assistance provided to get brushes Mr. S every evening before to or from the bathroom to score Oral hygiene. 16 October 20 18 Page GG-

314 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0130: Self- Care (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) provides Mrs. K water and toothpaste 3. Oral hygiene: At night, t he certified nursing assistant . Mrs. K then cleans half of her to clean her dentures. Mrs. K cleans her upper denture plate lower denture plate , but states she is tired and unable to finish cleaning her lower denture plate. The certified nursing ass istant finishes cleaning the lower denture plate and Mrs. K replaces the dentures in her mouth. Coding: GG0130B would be coded 03, Partial/moderate assistance. The helper provided less than half the effort Rationale: to complete oral hygiene . 4. Oral h ygiene: Mr. W is edentulous (without teeth) and his dentures no longer fit his gums. after the helper applies In the morning and evening, Mr. W begins to brush his upper gums , but cannot finish due to fatigue. gums toothpaste onto his toothbrush. He brushes his upper The certified nursing assistant completes the activity of oral hygiene by brushing his back lower gums. and his upper gums GG0130B would be coded 02, Substantial/m aximal a ssistance . Coding: the activity. The helper completes the activity by Rationale : The resident begins performing more than half the effort. 5. Oral h ygiene: Mr. G has Parkinson’s disease, resulting in tremors and incoordination. The certified nursing assistant retrieves all oral hygiene items for Mr. G and a pplies toothpaste to his toothbrush. Mr. G requires assistance to guide the toothbrush into his mouth and to steady his elbow while he brushes his teeth. Mr. G usually starts by brushing his upper and lower front teeth and the certified nursing assistant c ompletes the activity by brushing the rest of his teeth . Coding: GG0130B would be coded 02, Substantial/maximal assistance. to complete The helper provided more than half the effort for the resident Rationale: the activity of oral hygiene. 6. Oral hygiene: Ms. T has Lewy body dementia and multiple bone fractures. She does not understand how to use oral hygiene items nor does she understand the process of completing oral hygiene. The certified nursing assistant brushes her teeth and explains each step of the activity to engage cooperation from Ms. T; however, she requires full assistance for the activity of oral hygiene. Coding: GG0130B would be coded 01, Dependent. The helper provide d. s all the effort for the activity to be complete Rationale: 17 October 2018 Page GG-

315 RAI CMS’s CH 3: MDS Items [ GG] Manual Version 3.0 GG0130: Self- Care (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Oral h 7. teeth while sitting on the ygiene: Mr. D has experienced a stroke. He can brush his side of the bed, but when the certified nursing assistant hands him the toothbrush and toothpaste, he looks up at her puzzled what to do next. The certified nursing assistant cues Mr. D to put the toothpaste on the toothbrush and instructs him to brush his teeth. Mr. D then completes the task of brushing his teeth. GG0130B would be coded 04, Coding: Supervision or touching a ssistance . The helper provides verbal cues to assist the resident in completing the Rationale: activity of brushing his teeth. Ms. K su ygiene: Oral h 8. ffered a stroke a few months ago that resulted in cognitive limitations. She brushes her teeth at the sink, but is unable to initiate the task on her own. The occupational therapist cues Ms. K to put the toothpaste onto the toothbrush, brush all areas of her teeth, and rinse her mouth after brushing. The occupational therapist remains with Ms. K providing verbal cues until she has completed the task of brushing her teeth. Coding: GG0130B would be coded 04, Supervision or touching assistance. Rationale: The helper provides verbal cues to assist the resident in completing the activity of brushing h er teeth. Mrs. N has early stage amyotrophic lateral sclerosis. She starts brushing her Oral hygiene: 9. teeth and completes cleaning her upper teeth and part of her lower teeth when she becomes fatigued and asks the certified nursing assistant to help her finish the rest of the brushing. Coding: GG0130B would be coded 03, Partial/moderate assistance. Rationale: The helper provided less than half the effort to complete oral hygiene. Coding Tips for GG0130C, Toileting hygiene Toileting hygiene includes managing undergarments, clothing, and incontinence products • and performing perineal cleansing before and after voiding or having a bowel movement. If the resident does not usually use undergarments, then assess the resident’s need for assistance to manage lower-body clothing and perineal hygiene. • Toileting hygiene takes place before and after use of the toilet, commode, bedpan, or urinal. If the resident completes a bowel toileting program in bed, code Toileting hygiene based on the resident’s need for assistance in managing clothing and perineal cleansing. • If the resident has an indwelling urinary catheter and has bowel movements, code the Toilet hygiene item based on the amount of assistance needed by the resident before and after moving his or her bowels. 18 October 20 18 Page GG-

316 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0130: Self- Care (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Examples for GG0130C , Toileting hygiene Mrs. J uses a bedside commode. The certified nursing assistant provides 1. Toileting hygiene: steadying (touching) assistance as Mrs. J pulls down her pants and underwear before sitting down on the toilet. When Mrs. J is finished voiding or having a bowel movement, the certified nursing assistant provides steadying assistance as Mrs. J wipes her perineal area and pulls up her pants and underwear without assistance . Coding: GG0130C would be coded 04, Supervision or touching assistance. Rationale: The helper provides steadying (t ouching) assistance to the resident to complete toileting hygiene . 2. Toileting hygiene: Mrs. L uses the toilet to void and have bowel movements. Mrs. L is unsteady, so t he certified nursing assistant walks into the bathroom with her in case she needs help. During the assessment period has been present in the bathroom, but has , a staff member not needed to provide any physical assistance with managing clothes or cleansing. ssistance 130C would be coded 04, Supervision or touching a GG0 Coding: . Th e helper provides supervision as the resident performs the toilet hygiene Rationale: . The resident is unsteady and the staff provide supervision for safety reasons. activity Toileting hygiene: 3. Mrs. P has urinary urgency. As soon as she gets in the bathroom, she asks the certified nursing assistant to lift her gown and pull down her underwear due to her balance problems . After voiding, Mrs. P wipes herself and pulls her underwear back up. assistance . Coding: GG0130C would be coded 03, Partial/m oderate Rationale The helper provides more than touching assistance. The resident performs : more than half the effort; the helper does less than half the effort. The resident completes . two of the three toileting hygiene tasks . He requests the 4. Mr. J is morbidly obese and has a diagnosis of debility Toileting hygiene: use of a bedpan when voiding or having bowel movements and requires two certified nursing assistants to pull down his pants and underwear and mobilize him onto and off the bedpan. hygiene. Both certified nursing Mr. J is unable to complete any of his perineal /perianal assistants help Mr. J pull up his underwear and pants. GG0130C would be coded 01, Dependent. Coding: The assistance of two helpers was needed to complete the activity of Rationale: toileting hygiene. 19 October 20 18 Page GG-

317 GG] CMS’s CH 3: MDS Items [ Manual RAI Version 3.0 -day assessment period) Care (3 GG0130: Self- (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Toileting hygiene: M r. C has Parkinson’s disease and significant tremors that cause 5. intermittent difficulty for him to perform perineal hygiene after having a bowel movement in the toilet. He walks to the bathroom with close supervision and lowers his pants, but asks the certified nur sing assistant to help him with perineal hygiene after moving his bowels. He then pulls up his pants without assistance. Coding: GG0130C would be coded 03, Partial/m oderate assistance . The resident two of The helper provides less than half the effort. performs Rationale: the three toileting hygiene tasks by himself . Walking to the bathroom is not considered when scoring toileting hygiene. Ms. Q has a progressive neurological disease that affects her fine and 6. Toileting hygiene: gross motor coordination, balance, and activity tolerance. She wears a hospital gown and underwear during the day. Ms. Q uses a bedside commode as she steadies herself in standing with one hand and initiates pulling down her underwear with the other hand but needs assistance t o complete this activity due to her coordination impairment. After voiding, Ms. Q wipes her perineal area without assistance while sitting on the commode. When Ms. Q has a bowel movement, a certified nursing assistant performs perineal hygiene as Ms. Q needs to steady herself with both hands to stand for this activity. Ms. Q is usually too fatigued at this point and requires full assistance to pull up her underwear. GG0130C would be coded 02, Substantial/maximal assistance. Coding: The helper provided more than half the effort needed for the resident to Rationale: complete the activity of toileting hygiene. Coding Tips for GG0130E, Shower/bathe self • Shower/bathe self includes the ability to wash, rinse, and dry the face, upper and lower body, perineal area, and feet. Do not include washing, rinsing, and drying the resident’s back or hair. Shower/bathe self does not include transferring in/out of a tub/shower. Assessment of Shower/bathe self can take place in a shower or bath or at a sink (i.e., full • body sponge bath). If the resident bathes himself or herself and a helper sets up materials for bathing/showering, • then code as 05, Setup or clean-up assistance. • If the resident cannot bathe his or her entire body because of a medical condition, then code Shower/bathe self based on the amount of assistance needed to complete the activity. 20 October 20 18 Page GG-

318 GG] CMS’s CH 3: MDS Items [ Manual RAI Version 3.0 -day assessment period) Care (3 GG0130: Self- (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Examples for GG0130E, Shower/bathe self Shower/bathe self: 1. Mr. J sits on a tub bench as he washes, rinses, and dries himself. A certified nursing assistant stays with him to ensure his safety, as Mr. J has had instances of losing his sitting balance. The certified nursing assistant also provides lifting assistance as Mr. J g ets onto and off of the tub bench. 04 GG0130E would be coded Coding: Supervision or touching assistance. , The helper provides supervision as Mr. J washes, rinses, and dries Rationale: himself. The transfer onto or off of the tub bench is not considered when coding the Shower/bathe self activity. Shower/bathe self: Mrs. E has a severe and progressive neurological condition that has 2. affected her endurance as well as her fine and gross motor skills. She is transferred to the shower bench with partial/moderate assistance. Mrs. E showers while sitting on a tub bench and washes her arms and chest using a wash mitt. A certified nursing assistant then must help wash the remaining parts of her body, as a result of Mrs. E’s fatigue, to complete the activity. Mrs. E uses a long-handled shower to rinse herself but tires halfway through the task. The certified nursing assistant dries Mrs. E’s entire body. Coding: GG0130E would be coded 02, Substantial/maximal assistance. Rationale: than half of the task of showering, The helper assists Mrs. E with more which includes bathing, rinsing, and drying her body. The transfer onto the shower bench is not considered in coding this activity. Mr. Y has limited mobility resulting from his multiple and complex Shower/bathe self: 3. me dical conditions. He prefers to wash his body while sitting in front of the sink in his bathroom. A helper assists with washing, rinsing, and drying Mr. Y’s arms/hands, upper legs, lower legs, buttocks, and back. GG0130E would be coded 02, Substant ial/maximal assistance. Coding: Rationale: The helper completed more than half the activity. Bathing may occur at When coding this activity, do not include assistance provided with washing, the sink. rinsing, or drying the resident’s back. 21 October 20 18 Page GG-

319 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 -day assessment period) GG0130: Self-Care (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Coding Tips for GG0130F, Upper body dressing, GG0130G, Lower body dressing, and GG0130H, Putting on/taking off footwear • For upper body dressing, lower body dressing, and putting on/taking off footwear, if the resident dresses himself or herself and a helper retrieves or puts away the resident’s clothing, then code 05, Setup or clean-up assistance. When coding upper body dressing and lower body dressing, helper assistance with • buttons and/or fasteners is considered touching assistance. If donning and doffing an elastic bandage, elastic stockings, or an orthosis or prosthesis • occurs while the resident is dressing/undressing, then count the elastic bandage/elastic prosthesis as a piece of clothing when determining the amount of stocking/orthotic/ assistance the resident needs when coding the dressing item. • The following items are considered a piece of clothing when coding the dressing items: Upper body dressing examples: thoracic-lumbar-sacrum orthosis (TLSO), abdominal o binder, back brace, stump sock/shrinker, upper body support device, neck support, hand or arm prosthetic/orthotic. Lower body dressing examples: knee brace, elastic bandage, stump sock/shrinker, o -limb prosthesis. lower Footwear examples: ankle-foot orthosis (AFO), elastic bandages, foot orthotics, o orthopedic walking boots, compression stockings (considered footwear because of dressing don/doff over foot). • Upper body dressing items used for coding include bra, undershirt, T-shirt, button-down shirt, pullover shirt, dresses, sweatshirt, sweater, nightgown (not hospital gown), and pajama top. Upper body dressing cannot be assessed based solely on donning/doffing a hospital gown. • Lower body dressing items used for coding include underwear, incontinence brief, slacks, shorts, capri pants, pajama bottoms, and skirts. • Footwear dressing items used for coding include socks, shoes, boots, and running shoes. 22 October 20 18 Page GG-

320 GG] CMS’s CH 3: MDS Items [ Manual RAI Version 3.0 -day assessment period) GG0130: Self- Care (3 (cont.) on/Discharge (Start/End of Medicare Part A Stay) Admissi • For residents with bilateral lower extremity amputations with or without use of , the activity of putting on/taking off footwear may not occur. For example, the prosthe ses sis associated with the upper or lower leg. socks and shoes may be attached to the prosthe o If the resident performed the activity of putting on/taking off footwear immediately prior to the current illness, exacerbation, or injury, code as 88, Not attempted due to medical condition or safety concerns. If the resident did not perform the activity of putting on/taking off footwear o immediately prior to the current illness, exacerbation, or injury because the resident had bilateral lower-extremity amputations and the activity of putting on/taking off footwear was not performed during the assessment period, code as 09, Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. For residents with a single lower extremity amputation with or without use of a • prosthe sis, the activity of putting on/taking off footwear could apply to the intact limb or both the limb with the prosthe sis and the intact limb. o If the resident performed the activity of putting on/taking off footwear for the intact limb only, then code based upon the amount of assistance needed to complete the activity. If the resident performed the activity of putting on/taking off footwear for both the o intact limb and the prosthetic limb, then code based upon the amount of assistance needed to complete the activity. Examples for GG0130F, Upper body dressing side upper extremity weakness as a result of a stroke 1. Upper body dressing: Mrs. Y has right- and has worked in therapy to relearn how to dress her upper body. During the day, she requires a certified nursing assistant only to place her clothing next to her bedside. Mrs. Y can now use compensatory strategies to put on her bra and top without any assistance. At night she removes her top and bra independently and puts the clothes on the nightstand, and the certified nursing assistant puts them away in her dresser . GG0130F would be coded 05, Setup or clean-up assistance. Coding: Mrs. Y dresses and undresses her upper body and requires a helper only Rationale: to retrieve her clothing, that is, setting up the clothing for her use. The description refers to Mrs. Y as “independent” (when removing clothes), but she needs setup assistance, so she is not independent with regard to the entire activity of upper body sing. dres 23 October 20 18 Page GG-

321 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 -day assessment period) Care (3 GG0130: Self- Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Upper body dressing: 2. Mrs. Z wears a bra and a sweatshirt most days while in the SNF. She requires assistance from a certified nursing assistant to initiate the threading of her arms into her bra. Mrs. Z completes the placement of the bra over her chest. The helper hooks the bra clasps. Mrs. Z pulls the sweatshirt over her arms, head, and trunk. When undressing, s the sweatshirt . Mrs. Z slides the , with the helper assisting her with one sleeve Mrs. Z remove bra off, once it has been unclasped by the helper. Coding: GG0130F would be coded 03, Partial/moderate assistance. The helper provides assistance with threading Mrs. Z’s arms into her bra Rationale: and hooking and unhooking her bra clasps and assistance with removing one sleeve of Mrs. Z performs more than half of the effort. the sweatshirt. Mr. K sustained a spinal cord injury that has affected both movement 3. Upper body dressing: third of his left sleeve and strength in both upper extremities. He places his left hand into one- of his shirt with much time and effort and is unable to continue with the activity. A certified nursing assistant then completes the remaining upper body dressing for Mr. K. Coding: GG0130F would be coded 02, Substantial/maximal assistance. Rationale: Mr. K can perform a small portion of the activity of upper body dressing but requires assistance by a helper for more than half of the effort of upper body dressing. Examples for GG0130G, Lower body dressing 1. Mr. D is required to follow hip precautions as a result of recent hip Lower body dressing: surgery. He requires a helper to retrieve his clothing from the closet. Mr. D uses his adaptive equipment to assist in threading his legs into his pants. Because of balance issues, Mr. D needs the helper to steady him when standing to manage pulling on or pulling down his pants/undergarments. Mr. D also needs some assistance to put on and take off his socks and shoes. GG0130G would be coded 04, Supervision or touching assistance. Coding: A helper steadies Mr. D when he is standing and performing the activity of Rationale: lower body dressing, which is supervision or touching assistance. Putting on and taking off socks and shoes is not considered when coding lower body dressing 24 October 20 18 Page GG-

322 GG] CMS’s CH 3: MDS Items [ Manual RAI Version 3.0 -day assessment period) GG0130: Self- Care (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Lower body dressing: Mrs. M has severe rheumatoid arthritis and multiple fractures and 2. sprains due to a fall. She has been issued a knee brace, to be worn during the day. Mrs. M threads her legs into her garments, and pulls up and down her clothing to and from just below her hips. Only a little assistance from a helper is needed to pull up her garments over her hips. Mrs. M requires the helper to fasten her knee brace because of grasp and fine motor weakness. GG0130G would be coded 03, Partial/moderate assistance. Coding: A helper provides only a little assistance when Mrs. M is putting on her Rationale: lower extremity garments and fastening the knee brace. The helper provides less than half of the effort. Assistance putting on and removing the knee brace she wears is considered when determining the help needed when coding lower body dressing. Lower body dressing: 3. Mrs. R has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. R needs assistance from a helper to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks. Coding: GG0130G would be coded 03, Partial/moderate assistance. Rationale: A helper performs less than half the effort of lower body dressing (with a prosthesis considered a piece of clothing). The helper lifts, holds, or supports Mrs. R’s trunk or limbs, but provides less than half the effort for the task of lower body dressing. In contrast, coding level 04, Supervision or touching assistance, is used if the helper provides either verbal cues and/or only touching/steadying assistance as the resident completes the activity. Examples for GG0130H, Putting on/taking off footwear -side upper and Mr. M is undergoing rehabilitation for right Putting on/taking off footwear: 1. lower body weakness following a stroke. He has made significant progress toward his independence and will be discharged to home tomorrow. Mr. M wears an ankle-foot orthosis that he puts on his foot and ankle after he puts on his socks but before he puts on his shoes. He always places his AFO, socks, and shoes within easy reach of his bed. While sitting on the bed, he needs to bend over to put on and take off his AFO, socks, and shoes, and he occasionally loses his sitting balance, requiring staff to place their hands on him to maintain his balance while performing this task. 04, Supervision or touching assistance. GG0130H would be coded Coding: Mr. M puts on and takes off his AFO, socks, and shoes by himself; Rationale: however, because of occasional loss of balance, he needs a helper to provide touching assistance when he is bending over. 25 October 20 18 Page GG-

323 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0130: Self- Care (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Putting on/taking off footwear: 2. Mrs. F was admitted to the SNF for a neurologic condition and experiences visual impairment and fine motor coordination and endurance issues. She requires setup for retrieving her socks and shoes, which she prefers to keep in the closet. Mrs. F often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. Often a certified nursing assistant must first thread her socks or shoes over her toes, and then Mrs. F can complete the task. Mrs. F needs the certified nursing assistant to initiate taking off her socks and unstrapping the Velcro used for fastening her shoes. Coding: GG0130H would be coded 03, Partial/moderate assistance. Rationale: A helper provides Mrs. F with assistance in initiating putting on and taking off her footwear because of her limitations regarding fine motor coordination when putting on/taking off footwear. The helper completes more than half of the effort with this activity. Examples of Probing Conversations with Staff 1. Eating: Example of a probing conversation between a nurse and a certified nursing assistant : abilities eating regarding the resident’s “Please d Nurse: Once the food and liquid are escribe to me how Mr. S eats his meals. presented to him, does he use utensils to bring food to his mouth and swallow ?” Certified nursing assistant : “No, I have to feed him.” Nurse: “Do you always have to physically feed him or can he sometimes do some aspect of the eating activity with encouragement or cues to feed himself?” , he can’t do anything by himself. I scoop up each Certified n ursing assistant : “No portion of the food and bring the fork or spoon to his mouth. I try to encourage him to feed himself or to help guide the spoon to his mouth but he can’t hold the fork. I even tried en couraging him to eat food he could pick up with his fingers, but he will not eat unless he is completely assisted for food and liquid.” . In this example, the nurse inquired specifically how Mr. S requires assistance to eat his meals ked about instructions and physical assist ance. If this nurse had not asked probing The nurse as questions, he/she may not have received enough information to make an accurate assessment of the assis tance Mr. S received. Accurate coding is important for reporting on the type and activity definition fully. amount of care provided. B e su re to consider each 01, Dependent. 30A would be coded GG01 Coding: The resident requires complete assistance from the certified nursing Rationale: assistant to eat his meals. 26 October 20 18 Page GG-

324 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Care (3 GG0130: Self- -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Oral hygiene: Example of a probing conversation between a nurse deter mining a resident’s 2. oral hygiene score and a certified nursing assistant regard ing the resident’s oral hygiene routine: Nurse: “Does Mr s. K help with brushing her teeth ?” She can help clean her teeth “ : Certified nursing assistant .” Nurse: “How much help does she need to brush her teeth?” Certified nursing assistant : “ She usually gets tired after starting to brush her upper teeth. I have to brush most of her teeth.” In this example, the nurse inquired specifically how Mr s. K manages her oral hygiene. The ked about physical assist nurse as ance and how the resident performed the activity. If this nurse had not ask ed probing questions, he/she would not have received enough information to make an accurate assessment of the actual assist ance Mr s. K received. 30B would be coded GG01 maximal assistance. 02, Substantial/ Coding: The certified nursing assistant provides more than half the effort to complete Rationale: Mrs. K’s oral hygiene. s: Coding Tips Discharge Goal Discharge goals are coded with each Admission (Start of SNF PPS Stay) assessment. For the SNF Quality Reporting Program (QRP), a minimum of one self-care or mobility • discharge goal must be coded. However, facilities may choose to complete more than one using the six- Code the resident’s discharge goal (s) self -care or mobility discharge goal. point scale. Use of the “activity was not attempted” codes (07, 09, 10, and 88) is permissible to code discharge goal(s). Use of a dash is permissible for any remaining self- . Of note, at least one Discharge Goal must be care or mobility goals that were not coded indicated for either Self Using the dash in this allowed instance obility. after -Care or M does not affect Annual Payment Update ( APU ) the coding of at least one goal determination. clinicians can establish a resident’s Discharge Goal(s) at the time of • Licensed , qualified resident’s prior medical condition, admission admission based on the - assessment self , discussions with the resident and family, professional judgment, care and mobility status the professional’s standard of practice , expected treatments, the resident’s motivation to improve, anticipated length of stay, and the resident’s discharge plan . Goals should be established as part of the resident’s care plan. If the admission performance of an activity was coded 88, Not attempted due to medical • condition or safety concern during the admission assessment, a D oal may be ischarge G entered using the 6 -point scale if the resident is expected to be able to perform the activity by discharge. 27 October 20 18 Page GG-

325 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual GG0130: Self- Care (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Discharge Goal: Coding Examples igher H Day PPS Assessment Admission Performance than 5- 1. Discharge Goal Code I s Code If the qualified clinician determines that the resident is expected to make gains in function by code reported for D ischarge G discharge, the admission oal will be higher than the performance code. Day PPS Assessment Admission Performance 2. Discharge Goal Code I s the Same as 5- Code The clinician determines that a medically complex resident is not expected to qualified progress to a higher level of functioning during the SNF Medicare Part A stay; however, the clinician determines that the resident would be able to maintain her admission qualified clinician discusses functional status goals with the qualified functional performance level. The resident and her family and they agree that maintaining functioning is a reasonable goal. In this example, the Discharge Goal is coded at the same level as the resident’s admission performance code. Oral Hygiene 5 -Day PPS Assessment Admission Performance: In this example , the qualified clinician anticipates that the resident will have the same level of function for oral hygiene at admission and discharge. The resident’s 5-Day PPS admission performance code is coded and the Discharge Goal is coded at the same level. Mrs. E has stated her preference for participation twice daily in her oral hygiene activity. Mrs. E has severe arthritis, Parkinson’s disease, diabetic neuropathy, and renal failure. These conditions result in multiple impairments (e.g., limited endurance, weak grasp, slow Day PPS clinician observes Mrs. E’s 5- movements, and tremors). The qualified admission performance and discusses her usual performance with qualified clinicians, caregivers, and family to determine the necessary interventions for skilled therapy (e.g., positio ning of an adaptive toothbrush cuff, verbal cues, lifting, and supporting Mrs. E’s limb). The qualified clinician codes Mrs. E’s 5 -Day PPS assessment admission Substantial/maximal assistance. The helper performs more than half performance as 02, . the effort when lifting or holding her limb qualified clinician Oral Hygiene 5 -Day PPS Assessment Discharge Goal: The anticipates Mrs. E’s discharge performance will remain 02, Substantial/maximal qualified assistance. Due to Mrs. E’s progressive and degenerative condition, the clinician and resident feel that, while Mrs. E is not expected to make gains in oral hygiene performance, maintaining her function at this same level is desirable and achievable as a Discharge Goal. 28 October 20 18 Page GG-

326 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Care (3 -day assessment period) GG0130: Self- Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Day PPS Assessment Admission Performance than 5- 3. Discharge Goal Code I s L ower Code The qualified clinician determines that a resident with a progressive neurologic condition is services may slow the decline of function. expected to rapidly decline and that skilled therapy In this scenario, the D ischarge Goal code is lower than the resident’s 5- Day PP S assessment admission performance code. Mrs. T’s participation in skilled therapy is expected to slow down the ygiene: Toileting H pace of her anticipated functional code will Discharge Goal deterioration. The resident’s Day PPS Admission P erformance code. be lower than the 5- Toileting Hygiene 5 -Day PPS Assessment Admission Performance: Mrs. T has a progressive neurological illness that affects her strength, coordination, and endurance. Mrs. T prefers to use a bedside commode rather than incontinence undergarments for as long as possible. The certified nursing assistant currently supports Mrs. T while she is standing so that Mrs. T can release her hand from the grab bar (next to her bedside the bedside commode. When commode) and pull down her underwear before sitting onto Mrs. T has requires the helper finished voiding, she wipes her perineal area. Mrs. T then qualified clinician codes to support her trunk while Mrs. T pulls up her underwear. The the 5 -Day PPS assessment admission performance as 03, Partial/moderate assistance. The certified nursing assistant provides less than half the effort for Mrs. T’s toileting hygiene. Toileting H ygiene Discharge Goal: By discharge, it is expected that M rs. T will need assistance with toileting hygiene and that the helper will perform mor e than half the oal as 02, Su bstantial/maximal effort. The ischarge G qualified clinician codes her D assistance. 29 October 20 18 Page GG-

327 CMS’s Manual CH 3: MDS Items [ GG] Version 3.0 RAI obili GG0170: M -day assessment period) ty (3 Admission (Start of Medicare Part A Stay) 30 Page GG- 18 20 October

328 GG] CMS’s Manual CH 3: MDS Items [ Version 3.0 RAI GG0170: Mobility (3-day assessment period) (cont.) Admission (Start of Medicare Part A Stay) 31 Page GG- 20 October 18

329 CMS’s Manual CH 3: MDS Items [ GG] Version 3.0 RAI obili -day assessment period) GG0170: M ty (3 Discharge (End of Medicare Part A Stay) 32 Page GG- 18 20 October

330 CMS’s Manual CH 3: MDS Items [ GG] Version 3.0 RAI GG0170: Mobility (3 -day assessment period) Discharge (End of Medicare Part A Stay) (cont.) 33 GG- 2018 October Page

331 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 obili ty (3 -day assessment period) GG0170: M Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Item Rat iona le • During a Medicare Part A SNF stay , residents may have mobility limitations on admission . In addition, resident s may be at risk of further functional decline during their stay in the SNF . Steps for Assessment based on direct observation, performance mobility the as well as 1. Assess the resident’s clinicians, resident’s self -report and the reports of qualified DEFINITION during the direct care staff , or family three-day assessment period. CMS anticipates that a multidisciplinary team of USUAL PERFORMANCE qualified clinicians is involved in assessing the resident during A resident’s functional status the three-day assessment period. For Section GG, the can be impacted by the assessment period is the first three days of the Part A stay, environment or situations S tart of M ost R starting with the date in A2400B, ecent Medicare encountered at the facility. S tay . On admission, these items are completed only when Observing the resid ent’s interactions with others in Day PPS assessment). A0310B = 01 (5- different locations and 2. Resident s should be allowed to perform activities as circumstances is important independently as possible, as long as they are safe. for a comprehensive understanding of the 3. For the purposes of completing Section GG, a “ helper ” is resident’ If status. s functional - defined as facility staff who are direct employees and facility functional the resident’s contracted employees (e.g., rehabilitation staff, nursing agency status varies, record the staff). Thus, does not include individuals hired, compensated or ’s usual ability to resident ’s management and de of the facility not, by individuals outsi perform each activity. Do not , such as hospice staff, nursing/certified nursing administration record the resident ’s best assistant students, etc. Therefore, when helper assistance is performance and do not required because a resident’s performance is unsafe or of poor ’s worst record the resident according to ing y staff when scor quality, only consider facilit performance, but rather ’s usual record the resident amount of assistance provided. performance . Activities may be completed with or without assistive device(s). 4. Use of assistive device(s) to complete an activity should not affect coding of the activity. The admission functional assessment, when possible, should be conducted prior to the person 5. benefitting from treatment interventions in order to determine a true baseline functional status on admission. If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. Refer to facility, Federal, and State policies and procedures to determine which SNF staff 6. members may complete an assessment. Resident assessments are to be done in compliance with facility, F ederal, and State requirements. 20 34 Page GG- October 18

332 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili -day assessment period) GG0170: M ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Instruc tions Admission or Discharge Performance Coding • When coding the resident’s usual performance and the resident’s discharge goal(s), use -point scale, or one of the four “activity was not attempted” codes (07, 09, 10, and the six 88), to specify the reason why an activity was not attempted. • Independent : if the resident completes the activity by him/herself with no Code 06, assist ance from a helper. up assistance: • Code 05, Setup or clean- if the helper SETS UP or CLEANS UP; resident completes activ only prior to or following the activity, but not ity. Helper assists mple, the resident during the activity. For exa requires placement of a bed rail to facilitate up of a leg lifter or other assisti ve devices. rolling, or requires set Code 04, Supervision or touching assistance: if the helper provides VERBAL • CUES or TOUCHING/STEADYING assista nce as resident completes activ ity. Assista ivity or intermittently. For example, the nce may be provided throughout the act resident requires ver bal c ueing, coax ing, or gener al su pervision for safe ty to complete the act ivity; or resident may require only incidental help such as contact guard or steady ing assistance during the activity. rate assistance: ial/ mode Code 03, Part • if the helper does LESS THAN HALF the effort. Helper lifts, hold s, or supports trunk or limbs, but provides less than half the effort. For example, the resident requires assista nce s uch as partial weigh t- bearing assista nce, b ut HELPER does LESS THAN HALF the effort. Code 02, Subs • ial/ maxi tant mal assistance: if the helper does MORE THAN HALF the e ffort. Helper lifts or holds trunk or limbs and provides more than half the effort. • does none of the Code 01, Dependent : if the helper does ALL of the ef fort. Resident or m ore helpers is required for the effort to complete the activity . O r the assistance of two to complete the activity. resident ed: • Code 07, Resident r efus if the resident refused to complete t he act ivity. applicable: • Code 09, Not if the activity was not attempted and the resident did not perform this activ ity prior to the cu rrent illness, exacerbation, or injury. • Code 10, Not attempted due to environmental limitations: if the resident did not attempt this activity due to environmental limitations. Examples include lack of equipment and weather constraints. if Code 88, Not attempted due to med tion or safety concerns ical condi : • the activity was not atte ndition or safety concer mpted due to medical co ns. 35 October 20 18 Page GG-

333 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0170: M obili ty (3 -day assessment period) (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Admission or Discharge Performance Coding Tips • Admission: The 5 -Day PPS assessment (A0310B = 01) is the first Medicare -required assessment to be completed when the resident is admitted for a SNF Part A stay. o For the 5- Day PPS assessment, code the resident’ s functional status based on a ’s resident clinical assessment of the resident’s performance that occurs soon after the admission . This functional assessment must be completed within the first three days three arting with the date in A2400B, calendar days) of the Medicare Part A stay, st ( and the following two days, ending at 11:59 PM , Start of Most Recent Medicare Stay on day 3 . The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The scores should reflect the The assessment should occur resident’s status prior to any benefit from interventions. prior to the re sident benefitting from treatment interventions in order to determine the resident’s true admission baseline status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. The Part A PPS Discharge assessment is required to be completed when the • Discharge: resident’s Medicare Part A stay ends as documented in A2400C, End of Most Recent Medicare Stay, either as a standalone assessment when the resident’s Medicare Part A stay ends, but the resident remains in the facility; or may be combined with an OBRA the , Discharge if the Medicare Part A stay ends on the day of , or one day before resident’s Discharge Date (A2000). Please see Chapter 2 and Section A of the RAI Manual for additional details regarding the Part A PPS Discharge assessment. o For the Discharge assessment, (i.e., standalone Part A PPS or combined OBRA/Part code the resident’s discharge functional status, based on a clinical assessment A PPS), of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible. This functional assessment must be ’s Medicare Part A stay, completed within the last three calendar days of the resident from Medicare Part A and the two days prior to which includes the day of discharge . the day of discharge from Medicare Part A 36 October 20 18 Page GG-

334 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili -day assessment period) GG0170: M ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Admission and Discharge Performance Coding Tips General Coding Tips • When reviewing the medical record, interviewing staff, and observing the resident , be familiar with the definition each activity . For example, when assessing GG0170J, for Walk 50 feet with two turns, determine the type and amount of assistance required as the resident walks 50 feet . • If the resident does not attempt the activity and a helper does not complete the activity for the resident during the entire assessment period , code the reason the activity was not attempted. For example, code as 07, if the resident refused to attempt the activity ; code as did not occur at the the activity ( if the activity is not applicable for the resident , 09 time of the assessment prior to the current illness, exacerbation, or injury ); code as , and 10, if the resident was not able to attempt the activity due to environmental limitations; or code as 88 , if the resident was not able to attempt the activity due to a medical condition or safety concerns. • An activity can be completed independently with or without devices. If the resident has adaptive equipment, retrieves the equipment without assistance, and performs the activity independently using the device, enter code 06, Independent. If two or more helper • s are required to assist the resident to complete the activity, code as 01, Dependent. • To clarify your own understanding and observations about a resident’s performance of an activity, ask probing questions, beginning with the general and proceeding to the more specific. See examples of using probes when talking with staff at the end of this section. • A dash (“ -”) indicates “No information.” CMS expects dash use to be a rare occurrence. • Documentation in the medical record is used to support assessment coding of Section GG. D ata entered should be consistent with the clinical assessment documentation in the . This assessment can be conducted by appropriate healthcare resident’s medical record , and F policy and in accordance with local, S ederal tate personnel as defined by facility regulations. 37 October 20 18 Page GG-

335 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 -day assessment period) ty (3 obili GG0170: M Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Tips for Coding the Resident’s Usual Performance • When coding the resident’s usual performance, “effort” refers to the type and amount of assistance a helper provides in order for the activity to be completed. The six-point rating scale definitions include the follo wing types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance. Do not record the resident’s best performance, and do not record the resident’s worst • performance, but rather record the resident’s usual performance during the assessment period. • Code based on the resident’s performance. Do not record the staff’s assessment of the resident’s potential capability to perform the activity. If the resident performs the activity more than once during the assessment period and the • resident’s performance varies, coding in Section GG is based on the resident’s “usual performance,” which is identified as the resident’s usual activity/performance for any of the Self -Care or Mobility activities, not the most independent or dependent performance the assessment period. A provider may need to use the entire three-day assessment over period to obtain the resident’s usual performance. Examples and Coding Tips for Admission or Discharge Performance Note: The following are coding examples and coding tips for mobility item s. Some examples describe a single observation of the person completing the activity; other examples describe a completing an activity across different times of summary of several observations of the resident ent days. the day and differ Examples for GG0170A, Roll left and right 1. Roll left and right: Mrs. R has a history of skin breakdown. A nurse instructs her to turn onto her right side, providing step-by-step instructions to use the bedrail, bend her left leg, and then roll onto her right side. Mrs. R attempts to roll with the use of the bedrail, but indicates she cannot perform the task. The nurse then rolls her onto her right side. Next, Mrs. R is instructed to return to lying on her back, which she successfully completes. Mrs. R then requires physical assistance from the nurse to roll onto her left side and to return to lying on her back to complete the activity. GG0170A would be coded 02, Substantial/maximal assistance. Coding: Rationale: The nurse provides more than half of the effort needed for the resident to complete the activity of rolling left and right. This is because the nurse provides physical assistance to move Mrs. R’s body weight to turn onto her right side. The nurse provides the same assistance when Mrs. R turns to her left side and when she returns to her back. Mrs. R is able to return to lying on her back from her right side by herself. 38 October 20 18 Page GG-

336 Manual CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 GG0170: M obili ty (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) A physical therapist helps Mr. K turn onto his right side by instructing Roll left and right: 2. him to bend his left leg and roll onto his right side. He then instructs him on how to position his limbs to return to lying on his back and then to repeat a similar process for rolling onto his left side and then return to lying on his back. Mr. K completes the activity without physical assistance from the physical therapist. Coding: GG0170A would be coded 04, Supervision or touching assistance. Rationale: The physical therapist provides verbal cues (i.e., instructions) to Mr. K as he rolls from his back to his right side and returns to lying on his back, and then again as he performs the same activities with respect to his left side. The ph ysical therapist does not provide any physical assistance. had a stroke that resulted in paralysis on his right side and is Mr. Z 3. Roll left and right: recovering from cardiac surgery. He requires the assistance of two certified nursing assistants when rolling onto his right side and returning to lying on his back and also when rolling onto his left side and returning to lying on his back. Coding: GG0170A would be coded 01, Dependent. Rationale: Two certified nursing assistants are needed to help Mr. Z roll onto his left and right side and back while in bed. Roll left and right: Mr. M fell and sustained left shoulder contusions and a fractured left hip 4. and underwent an open reduction internal fixation of the left hip. A physician’s order allows him to roll onto his left hip as tolerated. A certified nursing assistant assists Mr. M in rolling onto his right side by instructing him to bend his left leg while rolling to his right side. Mr. M needs physical assistance from the certif ied nursing assistant to initiate his rolling right because of his left arm weakness when grasping the right bedrail to assist in rolling. Mr. M returns to lying on his back without assistance and uses his right arm to grasp the left bedrail to slowly roll onto his left hip and then return to lying on his back. Coding: GG0170A would be coded 03, Partial/moderate assistance. Rationale: The helper provides less than half the effort needed for the resident to complete the activity of rolling left and right. , Sit to lying 70B Examples for GG01 1. Sit to lying: Mrs. H requires assistance from a nurse to transfer from sitting at the edge of the bed to lying flat on the bed because of paralysis on her right side. The helper lifts and and lowers . H uses her arms to position her upper body positions Mrs. H ’s right leg. Mrs herself to a lying position flat on her back . ance. Coding: GG0170B would be coded 03, Partial/m oderate assist Rationale: A helper lifts Mrs. H ’s right leg and helps her position it as she moves from a seated to a lying position; the helper performs less than half of the effort . 39 October 20 18 Page GG-

337 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual GG0170: Mobility (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) 2. Sit to lying: Mrs. F requires assistance from a certified nursing assistant to get from a sitting position to lying flat on the bed because of postsurgical open reduction internal fixation healing fractures of her right hip and left and right wrists. The certified nursi ng assistant cradles and supports her trunk and right leg to transition Mrs. F from sitting at the side of the bed to lying flat on the bed. Mrs. F assists herself a small amount by bending her elbows and o the mattress only to straighten her trunk left leg while pushing her elbows and left foot int while transitioning into a lying position. ubstantial/maximal assistance. Coding: GG0170B would be coded 02, S Rationale: The helper provided more than half the effort for the resident to complete f sit to lying. the activity o 3. Sit to lying : Mrs. H requires assistance from two certified nursing assistants to transfer from sitting at the edge of the bed to lying flat on the bed due to paralysis on her right side, ified nursing assistants explain s to Mrs. H obesity , and cognitive limitations . One of t he cert each step of the sitting to lying activity. ed to get from sitting to a y assist full Mrs. H is then asked to perform the lying position on the bed. Mrs. H makes no attempt to assist when incremental steps of the activity. Coding: GG0170B would be coded 01, Dependent. Rationale: The assistance of two certified nursing assistants was needed to complete the activity of sit to lying . If two or more helper s are required t o assist the resident to complete an activity, code as 01, Dependent. Sit to lying: 4. Mr. F had a stroke about 2 weeks ago and is unable to sequence the necessary movements to complete an activity (apraxia). He can maneuver himself when transitioning tting on the side of the bed to lying flat on the bed if the certified nursing assistant from si provides verbal instructions as to the steps needed to complete this task. Coding: GG0170B would be c oded 04, Supervision or touching assistance . Rationale: A helper provides verbal cues in order for the resident to complete the activity of sit to lying flat on the bed. 5. Mrs. G suffered a traumatic brain injury three months prior to admission. She Sit to lying: ments from sitting on the side of the requires the certified nursing assistant to steady her move bed to lying flat on the bed. Mrs. G requires steadying (touching) assistance throughout the completion of this activity. GG0170B would be coded 04, Supervision or touching assistance. Coding: Rationale: des steadying assistance in order for the resident to complete A helper provi the activity of sit to lying flat on her bed. 40 October 2018 Page GG-

338 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0170: M obili ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) 6. Sit to lying: Mrs. E suffered a pelvic fracture during a motor vehicle accident. Mrs. E transfers from requires the certified nursing assistant to lift and position her left leg when she in her left sitting at the edge of the bed to lying flat on the bed due to severe pain vic area. pel Mrs. E uses her arms to position and lower her upper body to lying flat on the bed. Coding: GG0170B would be coded 03, Partial/m oderate assist ance. Rationale: A helper lifts Mrs. E ’s left leg and helps her position it as Mrs. E transitions from a seated to a lying position; the helper does less than half of the effort. requires Sit to 7. Mr. A suffered multiple vertebral fractures due to a fall off a ladder. He lying: from a sitting position to lying flat on the bed because of to get assistance from a therapist trunk and lifts both legs to assist significant pain in his lower back. The therapist supports his Mr . A from sitting at the side of the bed to lying flat on the bed. Mr. A assists himself a small transitioning into amount by raising one leg onto the bed and then bending both knees while a lying position. GG0170B would be coded 02, Substantial/maximal assistance. Coding: to complet e Rationale: The helper provided more than half the effort for the resident the activity of sit to lying. Coding Tips for GG0170C, Lying to sitting on side of bed • The activity includes resident transitions from lying on his or her back to sitting on the side of the bed with his or her feet flat on the floor and sitting upright on the bed without back support. The residents’ ability to perform each of the tasks within this activity and how much support the residents require to complete the tasks within this activity is assessed. • For item GG0170C, Lying to sitting on side of bed, clinical judgment should be used to determine what is considered a “lying” position for a particular resident. • If the resident’s feet do not reach the floor upon lying to sitting, the qualified clinician will determine if a bed height adjustment is required to accommodate foot placement on the floor. back. • Back support refers to an object or person providing support for the resident’s • clinician determines that bed mobility cannot be assessed because of the If the qualified degree to which the head of the bed must be elevated because of a medical condition, then code the activities GG0170A, Roll left and right, GG0170B, Sit to lying, and GG0170C, Lying to sitting on side of bed, as 88, Not attempted due to medical condition or safety concern. 41 October 20 18 Page GG-

339 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0170: M obili ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Examples for GG0170C, Lying to sitting on side of bed pushes up from the bed to get himself from a lying to 1. Lying to sitting on side of bed: Mr. B a seated position. The certified nursing assistant provide s steadying (touching) assistance as scoots himself to the edge of the bed and lowers his feet onto the floor. Mr. B Coding: GG0170C would be coded 04, Supervision or t ouching a ssistance . The helper provides touching assistance as the Rationale: resident moves from a lying to sitting position. 2. Lying to sitting on side of bed: Mr. B pushes up on the bed to attempt to get himself from a lying to a seated position as the occupational therapist provides much of the lifting assistance additional lifting necessary for him to sit upright. The occupational therapist provides ots himself to the e dge of the bed and lowers his feet to the floor. assistance as Mr. B sco Coding: . GG0170C would be coded 02, Substantial/maximal assistance he Rationale: The hel per provides lifting assistance (more than half the effort) as t resident moves f rom a l ying to sitting position. 3. Lying to sitting on side of bed: Ms. P is being treated for sepsis and has multiple infected wounds on her lower extremities. F ull assistance from the certified nursing assistant is needed to move Ms. P from a lying position to sitting on the side of her bed because she usually has pain in her lower extremities upon movement. GG0170C would be coded 01, Dependent. Coding: The helper fully completed the activity of lying to sitting on the side of bed Rationale: . for the resident 4. Lying to sitting on side of bed: Ms. H is recovering from a spinal fusion. She rolls to her right side and pushes herself up from the bed to get from a lying to a seated position. The provide therapist s verbal cues as Ms. H safely uses her hands and arms to support her trunk and avoid twisting as she raises herself from the bed. Ms. H then maneuvers to the edge of the bed , finally lower ing her feet to the floor to complete the activity . . GG0170C would be coded 04, Supervision or t ouching a Coding: ssistance The helper provides verbal cues as the resident moves from a lying to sitting Rationale: position and does not lift the resident during the activity. 42 October 20 18 Page GG-

340 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) GG0170: M obili ty (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Mr 5. Lying to sitting on side of bed: s. P is recovering from Guillain -Barre Syndrome with s. P’s trunk as she residual lower body weakness. The certified nursing assistant steadies Mr gets to a fully upright sitting position on the bed and lifts each leg toward the edge of the bed. Mr s. P then scoots toward the edge of the bed and places both feet flat on the floor. Mrs. P complete . s most of the effort to get from lying to sitting on the side of the bed Coding: GG0170C would be coded 03, Partial/moderate assistance. Rationale: The helper provided lifting assistance and less than half the effort for the resident to complete the activity of lying to sitting on side of bed. Coding Tip for GG0170D, Sit to stand ith the sit- • If a sit -to-stand (stand assist) lift is used and two helpers are needed to assist w to- stand lift, then code as 01, Dependent. Examples for GG01 70D , Sit to stand Sit to stand: Mr. M has osteoarthritis and is recovering from sepsis. Mr. M transitions from a 1. assistance of the sitting to a standing position with the steadying (touching) hand on nurse’s Mr. M’s trunk. Coding: GG0170D would be coded 04, Supervision or touching a ssistance . The helper provides touching assistance only. Rationale: 2. Sit to stand: Mrs. L has multiple healing fractures and multiple sclerosis, requiring two certified nursing assistants to assist her to stand up from sitting in a chair. GG0170D would be coded 01, Dependent. Coding: Rationale: . helpers to complete the activity Mrs. L requires the assistance of two 3. Sit to stand: Mr. B has complete t etraplegia and is currently unable to stand when getting out of bed. He transfers from his bed into a wheelchair with assistance. The activity of sit to stand is not attempted due to his medical condition. Coding: GG0170D would be coded 88, Not attempted due to medical condition or safety concerns. Rationale: The activity is not attempted due to the resident’s diagnosis of complete tetraplegia . clerosis with moderate weakness in her lower Sit to stand: 4. ateral s Ms. Z has amyotrophic l and upper extremities. Ms. Z has prominent foot drop in her left foot, requiring the use of an ankle foot orthosis (AFO) for standing and walking. The certified nursing assistant applies uses the walker to steady Ms. Z’s AFO and places the platform walker in front of her; Ms. Z herself once standing. The certified nursing assistant provides lifting assistance to get Ms. Z 43 October 20 18 Page GG-

341 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Care (3 GG0130: Self- -day assessment period) (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) ance to steady Ms. Z’s balance to complete to a standing position and must also provide assist the activity. Coding: GG0170D would be coded 02, S ubstantial/maximal assistance. Rationale: The helper provided lifting assistance and more than half of the effort for to complete the activity of sit to stand . the resident 5. Sit to stand: Ms. R has severe rheumatoid arthritis and uses forearm crutches to ambulate. The certified nursing assistant brings Ms. R her crutches and helps her to stand at the side of the bed. The certified nursing assistant provides some lifting assistance to get Ms. R to a standing position but provides less than half the effort to complete the activity. Coding: GG0170D would be coded 03, Partial/moderate assistance. Rationale: The helper provided lifting assistance and less than half the effort for the to complete the activity of sit to stand . resident Coding Tips for GG0170E, Chair/bed-to-chair transfer • g in a chair or to-chair transfer, begins with the resident sittin Item GG0170E, Chair/bed- wheelchair or sitting upright at the edge of the bed and returning to sitting in a chair or wheelchair or sitting upright at the edge of the bed. The activities of GG0170B, Sit to lying, and GG0170C, Lying to sitting on side of bed, are two separate activities that are not assessed as part of GG0170E. If a mechanical lift is used to assist in transferring a resident for a chair/bed- to-chair • transfer and two helpers are needed to assist with the mechanical lift transfer, then code as 01, Dependent, even if the resident assists with any part of the chair/bed- to-chair transfer. Examples for GG0170E, Chair/bed -to -chair transfer Chair/bed 1. -to-chair transfer: Mr. L had a stroke and currently is not able to walk. He uses a . When Mr. L gets out of bed, the certified nursing assistant moves wheelchair for mobility the wheelchair into the correct position and locks the brakes so that Mr. L can transfer into the wheelchair safely. Mr. L had been observed several other times to determine any safety concerns , and it was documented that he transfers safely without the need for supervision. after the certified nursing assistant Mr. L transfers into the wheelchair by himself (no helper) leaves the room . . Coding: GG0170E would be coded 05, Setup or c lean -up a ssistance is not able to walk, so he transfers Mr. L from his bed to a wheelchair when Rationale: ed. The helper provides setup assistance only. Mr. L transfers safely and getting out of b r. does not need supervision or physical assistance during the transfe 44 October 20 18 Page GG-

342 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Mobili -day assessment period) GG0170: ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Chair/bed -to-chair transfer: Mr. C is sitting on the side of the bed. He stands and pivots 2. assistance. The nurse reports into the chair as the nurse provides contact guard (touching) that one time Mr. C only required verbal cues for safety, but usually Mr. C requires touching assistance. Coding: GG0170E would be coded 04, Supervision or touching assistance. provides touching assistance during the transfers. Rationale: The helper morbid obes 3. Chair/bed -to-chair transfer: Mr. F ’s medical conditions include ity , diabetes mellitus, and sepsis, and he recently underwent bilateral above- the -knee amputations. Mr. F requires full ass istance with transfers from the bed to the wheel chair using a lift device. Two certified nursing assistants are required for safety to transfer Mr. F when using the device from the bed to a wheelchair . Mr. F is unable to assist in the transfer from his bed to the wheel chair. Coding: GG0170E would be coded 01, Dependent. The two helpers completed all the effort for the activity of chair/bed- to-chair Rationale: activity, to complete an s are required to assist the resident If two or more helper transfer. code as 01, Dependent. Chair/bed -to-chair transfer: Ms. P has metastatic bone cancer , severely affecting her 4. activities. Ms. P is motivated to ability to use her lower and upper extremities during daily assist with her transfers from the side of her bed to the wheelchair. Ms. P pushes herself up from the bed to begin the transfer while the therapist provides limited trunk support with weight -bearing assistance. Once standing, Ms. P shuffles her feet, turns , and slowly sits down into the wheelchair with the therapist providing trunk support with weight- bearing assistance. Coding: GG0170E would be coded 03, Partial/moderate assistance. ded less to complete than half of the effort for the resident The helper provi Rationale: -to-chair transfer. the activity of chair/bed Chair/bed -to-chair transfer: 5. M r. U ha d his left lower leg amputated due to gangrene on and strength in his right associated with his diabetes mellitus and he has reduced sensati leg. He has not yet received his below -the -knee prosthesis. Mr. U uses a transfer board for -to-chair transfers. The therapist places the transfer board under his buttock. Mr. U chair/bed then attempts to scoot from the bed onto the transfer board. Mr. U has reduced sensation in . The physical his hands and limited upper body strength , but assists with the transfer therapist assists him in side scooting by lifting his trunk in a rocking motion across the transfer board and into the wheelchair. Coding: GG0170E would be coded 02, Substantial/maximal assistance. than half of the effort for the resident to complete The helper provided more Rationale: -to-chair transfer. the activity of chair/bed 45 October 2018 Page GG-

343 Manual CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 GG0170: M obili ty (3 -day assessment peri od) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Examples for GG0170F, Toilet transfer Toilet transfer: 1. The certified nursing assistant moves the wheelchair footrests up so that Mr s. T can transfer from the wheelchair onto the toilet by herself safely. The certified nursing assistant is not present during the transfer, because supervision is not required. Once Mrs. T completes the transfer from the toilet back to the wheelchair , she flips the footrests back down herself. Coding: . ssistance GG0170F would be coded 05, Setup or c lean -up a Rationale: The helper provides setup assistance (moving the footrest out of the way) can transfer safely onto the toilet. before Mrs. T at with the certified Mrs. Q transfers onto and off the elevated toilet se Toilet transfer: 2. nursing assistant supervising due to her unsteadiness. GG0170F would be coded 04, Supervision or touching a ssistance . Coding: Rationale: The helper provides supervision as the resident transfers onto and off the toilet. The resident may use an assistive device. 3. Toilet transfer: Mrs. Y is anxious about getting up to use the bathroom. She asks the certified nursing assistant to stay with her in the bathroom as she gets on and off the toilet. The certified nursing assistant stays with h er, as requested, and provides verbal encouragement and instructions (cues) to Mrs. Y. ssistance . Coding: GG0170F would be coded 04, Supervision or touching a Rationale: The helper provides supervision/verbal cues as Mrs. Y transfers onto and off the toilet. 4. Toilet transfer: The certified nursing assistant provides steadying (touching) assistance as Mrs. Z lowers her underwear and then transfers onto the toilet. After voiding, Mrs. Z cleanses herself. She then stands up as the helper steadies her pulls up her and Mrs. Z underwear as the helper steadies her to ensure Mrs. Z does not lose her balance. Coding: GG0170F would be coded 04, Supervision or touching a ssistance . transfers onto and Rationale: The helper provides steadying assistance as the resident off the toilet. A ssistance with managing clothing and cleansing is coded under item GG0130C, Toileting h and is not considered when rating the Toilet transfer item. ygiene 46 October 20 18 Page GG-

344 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0170: Mobili ty (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) by providing weight supports Mrs. M’s trunk with a gait belt - Toilet transfer: The therapist as Mrs. M pivot s and lowers herself onto the toilet. bearing Coding: GG0170F would be coded 03, Part ial/moderate assistance. The helper provides less than half the effort to complete the activity. The Rationale: helper provided weight -bearing assistance as the resident transferred on and off the toilet. Toilet transfer: Ms. W has peripheral vascular disease and sepsis , resulting in lower extremity pain and severe weakness. Ms. W uses a bedside commode when having a bowel movement. The certified nursing assistant raises the bed to a height that facilitates the transfer activity. Ms. W initiates lifting her buttocks from the bed and in addition requires some of her weight to be lifted by the certified nursing assistant to stand upright. Ms. W then reaches and grabs onto the armrest provides weight - of the bedside commode to steady herself. The certified nursing assistant rotates and slowly bearing assistance as she lowers Ms. W onto the bedside commode. Coding: GG0170F would be coded 02, S ubstantial/maximal assistance. Rationale: The helper provided more than half of the effort for the resident to complet e the activity of toilet transfer. Toilet transfer: Mr. H has paraplegia incomplete, pneumonia, and a chronic respiratory condition. Mr. H prefers to use the bedside commode when moving his bowels. Due to his severe weakness, history of falls, and depende nt transfer status, two certified nursing assistants assist during the toilet transfer. would be coded 01, Dependent. GG0170F Coding: The activity required the assistance of two or more helpers for the res ident Rationale: to complete the activity. Mrs. S is on bedrest Toilet transfer: due to a medical complication . She uses a bedpan for bladder and bowel management. Coding: G G0170F would be coded 88, Not attempted due to medical condition or safety concerns. The resident r off a toilet due to being on bedrest does not transfer onto o Rationale: . because of a medical condition 47 October 2018 Page GG-

345 RAI CMS’s CH 3: MDS Items [ GG] Manual Version 3.0 -day assessment period) ty (3 obili GG0170: M (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Examples for GG0170 G, Car transfer 1. Mrs. W uses a wheelchair and ambulates for only short distances. She requires ransfer: Car t lifting assistance from a physical therapist to get from a seated position in the wheelchair to a standing position. The therapist provides trunk support when Mrs. W takes several steps during the transfer turn. Mrs. W lowers herself into the car seat with steadying assistance from the therapist. She lifts her legs into the car with support from the therapist. Coding: 02, Substantial/maximal assistance. GG0170G would be coded Although Mrs. W also contributes effort to complete the activity, the helper Rationale: contributed more than half the effort needed to transfer Mrs. W into the car by providing lifting assistance and trunk support. 2. Car transfer: During her rehabilitation stay Mrs. N works with an occupational therapist on transfers in and out of the passenger side of a car. On the day before discharge, when performing car transfers, Mrs. N requires verbal reminders for safety and light touching assistance. The therapist instructs her on strategic hand placement while Mrs. N transitions to sitting in the car’s passenger seat. The therapist opens and closes the door. Coding: GG0170G would be coded 04, Supervision or touching assistance. Rationale: The helper provides touching assistance as the resident transfers into the passenger seat of the car. Assistance with opening and closing the car door is not included in the definition of this item and is not considered when coding this item. –G0170L Walking Items Coding Tips for GG0170I • Walking activities do n ot need to occur during one session. Allowing a resident to rest between activities or completing activities at different times during the day or on different days may facilitate completion of the activities. do not consider the resident’s mobility • When coding GG0170 walking items, performance when using parallel bars. Parallel bars are not a portable assistive device. If safe, assess and code walking using a portable walking device. The turns included in item GG0170J, Walk 50 feet with two turns, are 90-degree turns. • The turns may be in the same direction (two 90-degree turns to the right or two 90- degree turns to the left) or may be in different directions (one 90-degree turn to the left and one 90-degree turn to the right). The 90-degree turn should occur at the person’s ability level and can include use of an assistive device (for example, cane). 48 October 20 18 Page GG-

346 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 -day assessment period) ty (3 obili GG0170: M Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Examples for GG0170I, Walk 10 feet Mrs. C has resolving sepsis and has not walked in three weeks because of her : 1. Walk 10 feet medical condition. A physical therapist determines that it is unsafe for Mrs. C to use a walker, and the resident only walks using the parallel bars. On day 3 of the Admission assessment period, Mrs. C walks 10 feet using the parallel bars while the therapist provides substantial weight-bearing support throughout the activity. GG0170I would be coded 88, Not attempted due to medical condition or safety Coding: concerns. When assessing a resident for GG0170 walking items, do not consider : Rationale walking in parallel bars, as parallel bars are not a portable assistive device. If the resident is unable to walk without the use of parallel bars because of his or her medical condition or safety concerns, use code 88, Activity not attempted due to medical condition or safety concerns. Walk 10 feet: 2. Mr. L had bilateral amputations three years ago, and prior to the current admission he used a wheelchair and did not walk. Currently Mr. L does not use prosthetic devices and uses only a wheelchair for mobility. Mr. L’s care plan includes fitting and use of bilateral lower extremity prostheses. Coding: GG0170I would be coded 09, Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Rationale: When assessing a resident for GG0170I, Walk 10 feet, consider the day assessment resident’s status prior to the current episode of care and current three- status. Use code 09, Not applicable, because Mr. L did not walk prior to the current episode of care and did not walk during the three-day assessment period. Mr. L’s care plan includes fitting and use of bilateral prostheses and walking as a goal. A discharge goal for any admission performance item skipped may be entered if a discharge goal is determined as part of the resident’s care plan. 3. Mrs. C has Parkinson’s disease and walks with a walker. A physical therapist Walk 10 feet: must advance the walker for Mrs. C with each step. The physical therapist assists Mrs. C by physically initiating the stepping movement forward, advancing Mrs. C’s foot, during the activity of walking 10 feet. GG0170I would be coded 02, Substantial/maximal assistance. Coding: A helper provides more than half the effort as the resident completes the Rationale: activity. 49 October 20 18 Page GG-

347 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual -day assessment period) ty (3 GG0170: M obili Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) has bilateral upper extremity tremors, lower extremity weakness, and 4. Walk 10 feet : Mr. O Parkinson’s disease. A therapy assistant guides and steadies the shaking, rolling walker forward while cueing Mr. O to take larger steps. Mr. O requires steadying at the beginning of the walk and progressively requires some of his weight to be supported for the last two feet of the 10-foot walk. Coding: GG0170I would be coded 03, Partial/moderate assistance. Rationale: The helper provides less than half the effort required for the resident to compl ete the activity, Walk 10 feet. While the helper guided and steadied the walker during the walk, Mr. O supported his own body weight with his arms and legs and propelled his legs forward for 8 of the 10 feet. The helper supported part of Mr. O’s weight only for 2 of the 10 feet ; thus Mr. O contributed more than half the effort. Mrs. U has an above-the-knee amputation and severe rheumatoid arthritis. Walk 10 feet: 5. Once a nurse has donned her stump sock and prosthesis, Mrs. U is assisted to stand and uses her rolling walker while walking. The nurse places his hand on Mrs. U’s back to steady her toward the last half of her 10-foot walk. GG0170I would be coded Coding: 04, Supervision or touching assistance. A helper provides touching assistance in order for the resident to complete Rationale: the activity of Walk 10 feet. Assistance in donning the stump stock, prosthesis, and getting from a sitting to standing position is not coded as part of the Walk 10 feet item. Examples for GG0170J, Walk 50 feet with two turns Walk 50 feet with two turns: A therapist 1. provides steadying assistance as Mrs. W gets up from a sitting position to a standing position. After the therapist places Mrs. W’s walker within reach, Mrs. W walks 60 feet down the hall with two turns without any assistance from the therapist . No supervision is required while she walks. -up a lean . ssistance Coding: GG0170J would be coded 05, Setup or c Mrs. W walks more than 50 feet and makes two turns once the helper places Rationale: the walker within reach. Assistance with getting from a sitting to a standing position is coded separately under the item GG0170D, Sit to stand (04, Supervision or touching assistance). Walk 50 feet with two turns: 2. Mrs. P walks 70 feet with a quad cane, completing two turns during the walk. The therapist provides steadying assistance only when Mrs. P turns. Coding: GG0170J would be coded 04, Supervision or touching a ssistance . resident Rationale: The helper provides touching assistance as the walks more than 50 feet and makes two turns. The resident may use an assistive device. 50 October 20 18 Page GG-

348 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili -day assessment period) GG0170: M ty (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Walk 50 feet with two turns: 3. Mrs. L is unable to bear her full weight on her left leg. As she walks 60 feet down the hall with her crutches and makes two turns, the certified nursing assistant supports her trunk providing weight-bearing assistance . Coding: GG0 170J would be coded 03, P artial/m oderate assistance . Rationale: walks more than 50 feet The helper provides trunk support as the resident and makes two turns. 4. Walk 50 feet with two turns: Mr. T walks 50 feet with the therapist providing trunk support and the therapy assistant providing supervision. Mr. T walks the 50 feet with two turns. Coding: GG0170J would be coded 01, Dependent. Rationale: Mr. T requires two helpers to complete the activity. 5. toid knee amputation, severe rheuma Mrs. U has an above-the- with two turns: Walk 50 feet arthritis, and uses a prosthesis. Mrs. U is assisted to stand and, after walking 10 feet, requires progressively more help as she nears the 50-foot mark. Mrs. U is unsteady and typically loses her balance when turning, requiring significant support to remain upright. The therapist provides significant trunk support for about 30 to 35 feet . Coding: GG0170J would be coded 02, Substantial/maximal assista nce. of the effort for the Rationale: The helper provided more than half resident to complete the activity of walk 50 feet with two turns. Examples for GG0170K, Walk 150 feet 1. Walk 150 feet: Mrs. D walks down the hall using her walker and the certified nursing assistant usually needs to provide touching assistance to Mrs. D, who interm ittently loses her balance while she uses the walker . GG0170K would be coded 04, Supervision or touching assistance. Coding: Rationale: The helper provides touching assistance intermittently throughout the activity. Mr . R has endurance limitations due to heart failure and has only walked Walk 150 feet: 2. about 30 feet during the 3-day assessment period. He has not walked 150 feet or more during the assessment period, including with the physical therapist who has been working with Mr. R. The therapist speculates that Mr. R could walk this distance in the future with additional assistance. GG0170K would be coded 88, Activity not attempted due to medical condition Coding: or safety concerns , and the resident’s ability to walk a shorter distance would be coded in item GG0170I. The resident did not complete the activity, and a helper cannot complete the activity for the resident. activity was not attempted. The Rationale: 51 October 20 18 Page GG-

349 Version 3.0 CMS’s CH 3: MDS Items [ GG] RAI Manual GG0170: M obili ty (3 -day assessment period) (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) 3. Mrs. T has an unsteady gait due to balance impairment. Mrs. T walks the Walk 150 feet: he physical therapist supports length of the hallway using her quad cane in her right hand. T her trunk, helping her to maintain her balance while ambulating. The therapist provides less than half of the effort to walk the 160-foot distance. Coding: GG0170K would be coded 03, Partial/moderate assistance. Rationale: The helper provides less than half of the effort for the resident to complete the activity of walking at least 150 feet. Mr. W, who has Parkinson’s disease, walks the length of the hallway using Walk 150 feet: 4. ight his rolling walker. The physical therapist provides trunk support and advances Mr. W’s r leg in longer strides with each step. The therapist occasionally prevents Mr. W from falling is balance during the activity. as he loses h Coding: GG0170K would be coded 02, Substantial/maximal assistance. Rationale: The helper provides more than half the effort for the resident to complete the activity of walk 150 feet. Example for GG0170L, Walking 10 feet on uneven surfaces Mrs. N has severe joint degenerative disease and is 1. Walking 10 feet on uneven surfaces: recovering from sepsis. Upon discharge Mrs. N will need to be able to walk on the uneven and sloping surfaces of her driveway. During her SNF stay, a physical therapist takes Mrs. N outside to walk on uneven surfaces. Mrs. N requires the therapist’s weight-bearing assistance less than half the time during walking in order to prevent Mrs. N from falling as she navigates walking 10 feet over uneven surfaces. Coding: GG0170L would be coded 03, Partial/moderate assistance. Mrs. N requires a helper to provide weight-bearing assistance several Rationale: times to prevent her from falling as she walks 10 feet on uneven surfaces. The helper contributes less than half the effort required for Mrs. N to walk 10 feet on uneven surfaces. Example for GG0170M, 1 step (curb) Mrs. Z has had a stroke; she must be able to step up and down one step to 1 step (curb): 1. enter and exit her home. A physical therapist provides standby assistance as she uses her quad cane to support her balance in stepping up one step. The physical therapist provides steadying assistance as Mrs. Z uses her cane for balance and steps down one step. Coding: GG0170M would be coded 04, Supervision or touching assistance. A helper provides touching assistance as Mrs. Z completes the activity of Rationale: stepping up and down one step. 52 October 20 18 Page GG-

350 CMS’s CH 3: MDS Items [ GG] RAI Version 3.0 Manual GG0170: M obili ty (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Example for GG0170N, 4 steps Mr. J has lower body weakness, and a physical therapist provides steadying 4 steps: 1. assistance when he ascends 4 steps. While descending 4 steps, the physical therapist provides trunk support (more than touching assistance) as Mr. J holds the stair railing. Coding: GG0170N would be coded 03, Partial/moderate assistance. Rationale: A helper provides touching assistance as Mr. J ascends 4 steps. The helper provides trunk support (more than touching assistance) when he descends the 4 steps. Example for GG0170O, 12 steps 1. from a stroke resulting in motor issues and poor endurance. 12 steps: Ms. Y is recovering Ms. Y’s home has 12 stairs, with a railing, and she needs to use these stairs to enter and exit her home. Her physical therapist uses a gait belt around her trunk and supports less than half of the effort as Ms. Y ascends and then descends 12 stairs. GG0170O would be coded 03, Partial/moderate assistance. Coding: The helper provides less than half the required effort in providing the Rationale: necessary support for Ms. Y as she ascends and descends 12 stairs. Examples for GG0170P, Picking up object 1. Picking up object: Mr. P has a neurologic condition that has resulted in balance problems. He wants to be as independent as possible. Mr. P lives with his wife and will soon be discharged from the SNF. He tends to drop objects and has been practicing bending or stooping from a standing position to pick up small objects, such as a spoon, from the floor. An occupational therapist needs to remind Mr. P of safety strategies when he bends to pick up objects from the floor, and she needs to steady him to prevent him from falling. GG0170P would be coded 04, Supervision or touching assistance. Coding: Rationale: A helper is needed to provide verbal cues and touching or steadying assistance when Mr. P picks up an object because of his coordination issues. 2. Picking up object: Ms. C has recently undergone a hip replacement. When she drops items she uses a long-handled reacher that she had been using at home prior to admission. She is ready for discharge and can now ambulate with a walker without assistance. When she drops object s from her walker basket she requires a certified nursing assistant to locate her long- handled reacher and bring it to her in order for her to use it. She does not need assistance to pick up the object after the helper brings her the reacher. Coding: GG017 0P would be coded 05, Setup or clean-up assistance. The helper -up assistance so that Ms. C can use her long- Rationale: provides set handled reacher. 53 October 20 18 Page GG-

351 RAI CMS’s CH 3: MDS Items [ GG] Manual Version 3.0 -day assessment period) ty (3 GG0170: M obili (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Coding Tips for GG0170R and GG0170S, Wheelchair Items The intent of the wheelchair mobility items is to assess the ability of residents who are • learning how to self-mobilize using a wheelchair or who used a wheelchair prior to admission. Use clinical judgment to determine whether a resident’s use of a wheelchair is for self -mobilization as a result of the resident’s medical condition or safety. • Do not code wheelchair mobility if the resident uses a wheelchair only when transported tions within the facility or for staff convenience (e.g., because the resident between loca assessment of the resident’s walks slowly). Only code wheelchair mobility based on an wheelchair. ability to mobilize in the If the resident walks and is not learning how to mobilize in a wheelchair, and only uses a • wheelchair for transport between locations within the facility, code the wheelchair gateway items at admission and/or discharge—GG0170Q1 and/or GG0170Q3, Does the resident use a wheelchair/scooter?—as 0, No, and skip all remaining wheelchair questions. • Admission assessment for wheelchair items should be coded for residents who used a wheelchair prior to admission The responses for gateway admission and discharge wheelchair items (GG0170Q1 o and GG0170Q3) do not have to be the same on the Admission and Discharge assessments. If a wheelchair is used for transport purposes only, then GG0170Q1 and/or GG0170Q3, • Does the resident use a wheelchair or scooter? is coded as 0, No; then follow the skip pattern to continue coding the assessment. o Example of using a wheelchair for transport convenience: A resident is transported in a wheelchair by staff between her room and the therapy gym or by family to the facility cafeteria, but the resident is not expected to use a wheelchair afte r discharge. • degree The turns included in item GG0170R (wheeling 50 feet with two turns) are 90- turns. The turns may be in the same direction (two 90-degree turns to the right or two 90- degree turns to the left) or may be in different directions (one 90-degree turn to the left and one 90-degree turn to the right). The 90-degree turn should occur at the person’s ability level. 54 October 20 18 Page GG-

352 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili -day assessment period) GG0170: M ty (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Example for GG0170Q1 , Does the resident use a wheelchair/scooter? 1. Does the resident use a wheelchair/scooter? On admission, Mr. T wheels himself using a manual wheelchair, but with difficulty due to his severe osteoarthritis and COPD. Coding: would be coded 1, Yes. The admission performance codes for 1 GG0170Q wheelchair item s GG0170R and GG0170S are coded; in addition, the type of wheelchair Mr. T uses for GG0170RR1 is indicated as code 1, Manual. If wheelchair goal(s) are clinically indicated , then wheelchair goals can be coded . Rationale the resident’s The resident currently uses a wheelchair. Coding : performance and the type of wheelchair (manual) is indicated. Wheeling goal(s) if clinically indicated may be coded. Examples for GG0170R, Wheel 50 feet with two turns, a nd GG0170RR, Indicate the type of wheelchair/scooter used Mrs. M is unable to bear any weight on her right leg due to a Wheel 50 feet with two turns: 1. he certified nursing assistant p recent fracture. T rovides steadying assistance when Mrs. M from the bed into the wheelchair. Once in her wheelchair, Mrs. M ring transfer propels herself about 60 feet down the hall using her left leg and makes two turns without any physical assistance or supervision. GG0170R would be coded 06, Independent. Coding: Rationale: The resident wheels herself more than 50 feet. Assistance provided with the transfer is not considered when scoring W heel 50 feet with two turns . There is a separate item for scoring bed -to-chair transfers. Indicate the type of wheelchair/scooter used rs. M used a manual e above example M : In th 2. wheelchair during the 3 -day assessment period. Coding: GG0170RR would be coded 1, Manual . Mrs. M used a manual wheelchair Rationale: during the 3-day assessment period. is very 3. Mr. R motivated to use his motorized wheelchair with : Wheel 50 feet with two turns clerosis , and an adaptive throttle for speed and steering. Mr. R has amyotrophic l ateral s extremities is very difficult. The therapy assistant is required to moving his upper and lower walk next to Mr. R for frequent readjustments of his hand position to better control the steering and speed throttle. Mr. R often drives too close to corners, becoming stuck near doorways upon turning, preventing him from continuing to mobilize/wheel himself. The therapy assistant backs up Mr. R’s wheelchair for him so that he may continue mobilizing/wheeling himself. 55 October 20 18 Page GG-

353 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual -day assessment period) GG0170: Mobility (3 (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Coding: would be coded 03, Partial/moderate assistance. GG0170R Rationale: The helper provided less than half of the effort for the resident to complete the activity, Wheel 50 feet with two turns. 4. Indicate the type of wheelchair/scooter used : In th e above example M r. R used a motorized wheelchair during the 3 -day assessment period. GG0170RR would be coded 2, M otorized. Coding: Mr. R used a motorized wheelchair during the 3 -day assessment period. Rationale: 5. Wheel 50 feet with two turns: Mr. V had a spinal tumor resulting in paralysis of his lower extremities. The therapy assistant provides verbal instruction for Mr. V to navigate his manual wheelchair in his room and into the hallway while making two turns. Coding: GG0170R would be coded 04, Supervision or touching assistance. Rationale: The helper provided verbal cues for the resident to complete the activity , Wheel 50 feet with two turns. example M e above In th : Indicate the type of wheelchair/scooter used used a manual r. V 6. wheelchair during the 3 -day assessment period. GG0170RR would be coded 1, Manual . Coding: Mr. V used a manual wheelchair during the 3- day assessment period. Rationale: 7. Wheel 50 feet with two turns: Once seated in the manual wheelchair, Ms. R wheels about to push the wheelchair an 10 feet in the corridor , then ask s the certified nursing assistant additional 40 feet . her bathroom then turning into into her room and turning GG0170R would be coded 02, Substantial/maximal assistance . Coding: Rationale: The helper provides more than half the effort to assist the resident to . complete the activity 8. Indicate the type of wheelchair/scooter used : In th e above example Ms. R used a manual wheelchair during the 3 -day assessment period. Coding: GG0170RR would be coded 1, Manual . day assessment period. Ms. R used a manual wheelchair during the 3- Rationale: 56 October 2018 Page GG-

354 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili GG0170: M -day assessment period) ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Examples for GG0170S, Wheel 150 feet and GG0170SS , Indicate the type of wheelchair/scooter used 1. Wheel 150 feet : Mr. G always uses a motorized scooter to mobilize himself down the hallway and the certified nursing assistant provides cues due to safety issues (to avoid the walls). running into Coding: GG0170S would be coded 04, Supervision or touching assistance. Rationale: The helper provides verbal cues to complete the activity. 2. Indicate the type of wheelchair/scooter used : In the example above, Mr. G uses a motorized scooter. Coding: GG0170SS would be coded 2, Motorized. Rationale: Mr. G used a motorized scooter during the 3-day assessment period. Wheel 150 feet: 3. -knee prosthetic limb. Mr. N has peripheral -the Mr. N uses a below neuropathy and limited vision due to complications of diabetes. Mr. N’s prior preference was to ambulate within the home and use a manual wheelchair when mobilizing himself within the community. Mr. N is assessed for the activity of 150 feet wheelchair mobility. Mr. N’s usual performance indicates a helper is needed to provide verbal cues for safety due to vision deficits. ssistance Coding: GG0170S would be coded 04, Supervision or touching a . Rationale: Mr. N requires the helper to provide verbal cues for his safety when using a wheelchair for 150 feet. 4. Indicate the type of wheelchair/scooter used : In th e above example M r. N used a manual wheelchair during the 3 -day assessment period. Coding: anual. GG0170SS would be coded 1, M Rationale: Mr. N used a manual wheelchair during the 3-day assessment period. Wheel 150 feet : has multiple sclerosis, resulting in extreme muscle weakness and 5. Mr. L minimal vision impairment. Mr. L uses a motoriz ed wheelchair with an adaptive joystick to control both the speed and steering of the motorized wheelchair . He occasionally needs nd requires assistance from the nurse for backing reminders to slow down around the turns a up the scooter when barriers are present. Coding: GG0170S would be coded 03, Partial/moderate assistance. of The helper provides less than half of the effort to complete the activity Rationale: wheel 150 feet. 57 October 20 18 Page GG-

355 CMS’s RAI Manual CH 3: MDS Items [ GG] Version 3.0 Mobili ty (3 GG0170: -day assessment period) (cont.) Admission/Discharge (Start/End of Medicare Part A Stay) Indicate the type of wheelchair/scooter used : M r. L used a m otorized wheelchair during 6. -day assessment period. the 3 Coding: GG0170SS would be coded 2, M otorized. Mr. L used a motorized wheelchair during the 3 -day assessment period. Rationale: 7. : Mr. M has had a mild stroke, resulting in muscle weakness in his right Wheel 150 feet -propel upper and lower extremities. Mr. M uses a manual wheelchair. He usually can self eet but needs assistance from a helper to complete the distance of 150 himself about 60 to 70 f feet. GG0170S would be coded 02, Substantial/Maximal assistance. Coding: The helper provides more than half of the effort to complete the activity of Rationale: wheel 150 feet . In th : the type of wheelchair/scooter used r. M used a manual example, M 8. e above Indicate -day assessment period. wheelchair during the 3 Coding: GG0170SS would be coded 1, M anual. day assessment period. Mr. M used a manual wheelchair during the 3- Rationale: 9. Wheel 150 feet : Mr. A has a cardiac condition with medical precautions that do not allow him to participate in wheelchair mobilization. Mr. A is completely dependent on a helper to wheel him 150 feet using a manual wheelchair. would be coded 01, Dependent Coding: GG0170S . to The helper provides all the effort and the resident does none of the effort Rationale: of wheel 150 feet . complete the activity r. A is wheeled 10. Indicate the type of wheelchair/scooter used : In th e above example, M using a manual wheelchair du ring the 3 -day assessment period. Coding: GG0170SS would be coded 1, M anual. during the 3 -day assessment Mr. A is assisted us ing a manual wheelchair Rationale: period. 58 October 2018 Page GG-

356 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual obili GG0170: M -day assessment period) ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Example s of Probing Conversations with Staff mining a nurse deter 1. Sit to lying: Example of a probing conversation between a resident’s score for sit to lying and a certified nursing assistant regarding the resident’s bed mobility: Nurse: “Please d escribe how Mrs. H moves herself from sitting on the side of the bed to she is sitting on the side of the bed, how does she move to lying flat on the bed. When lying on her back?” with some help Certified nursing as sistant: “She can lie down .” Nurse: “Please describe how much help she needs and exactly how you help her.” , but once I do that, Certified nursing assistant: “I have to lift and position her right leg use her arms to position her upper body.” she can In this example, the nurse inquired specifically about how Mrs. H moves from a sitting position to a lying ance. position. The nurse asked about physical assist GG0170B would be coded 03, Partial/moderate assistance. Coding: Rationale: The certified nursing assistant lifts Mrs. H’s right leg and helps her position it as she moves from a sitting position to a lying position. The helper does less than half the effort. 2. Lying to sitting on side of bed: Example of a probing conversation between a nurse deter mining a resident’s score for lying to sitting on side of bed and a certified nursing regarding the resident’s bed mobility: assistant Nurse: escribe how Mrs. L moves herself in bed. When she is in bed, how does “Please d she move from lying on her back to sitting up on the side of the bed?” Certified nursing assistant: “She can s it up by herself.” Nurse: “She sits up without any instructions or physical help?” “No, I have to remind her to check on the position of her Certified nursing assistant: arm that has limited movement and sensation as she moves in the bed, but once I remind do it herself.” her to check her arm, she can In this example, the nurse inquired specifically about how Mrs. L moves from a lying ked about instructions and physical assist position to a sitting position. The nurse as ance. 04, Supervision or touching assistance. Coding: GG0170C would be coded Rationale: provides verbal instructions as the resident The certified nursing assistant moves from a lying to sitting position. 59 October 20 18 Page GG-

357 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Mobili -day assessment period) GG0170: ty (3 Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Sit to stand: Example of a probing conversation between a nurse deter mining a resident’s sit 3. certified nursing assistant to stand score and a resident’s sit to stand ability : regarding the Nurse: escribe how Mrs. L usually moves from sitting on the side of the bed or “ Please d chair to a standing position. Once she is sitting, how does she get to a standing position ?” Certified nursing assistant : “ She needs help to get to sitting up and then standing .” Nurse: “ I’d like to know how much help she needs for safely rising up from sitting in a chair or sitting on the bed to get to a standing position.” “ She needs two peopl e to assist her to stand up from sitting Certified nursing assistant: on the side of the bed or when she is sitting in a chair.” In this exa inquired specifically about how Mrs. L moves from a sitting mple, the nurse position to a standing position and clarified that this did not inclu de any other positioning to be included in the answer . The nurse s pecifical ly as ked about physical assist ance. Coding: GG0170D would be c oded 01, Dependent . Mrs. L requires the assistance of two he lpers to complete the activity. Rationale: Chair/bed 4. a nurse a probing conversation between Example of -to-chair transfer: certified nursing assistant deter a resident’s score for chair/bed -to-chair transfer a nd a mining regarding the resident’s chair/bed -to-chair transfer ability : escribe how Mr. C Nurse: “ Please d moves into the chair from the bed. When he is sitting at the side of the bed , how much help does he need to move from the bed to the chair ?” Certified nursing assistant: “ He needs me to help him move from the bed to the chair .” , setup, or es he help with these transfers when you give him any instructions Nurse: “ Do ?” physical help Certified nursing assistant: “ Yes, he will follow some of my instructions to get ready to I transfer, such as moving his feet from being spread out to placing them under his knees. have to place the chair close to the bed and then I lift him because he is very weak. I then tell him to reach for the armrest of the chair. Mr. C follows these directions and that helps hair. He does help with the transfer.” a little in transferring him from the bed to the c about how Mr. C In this exa mple, the nurse inquired specifically moves from sitting on the ance, side of the bed to sitting in a chair. The nurse as ked a bout instructions , physical assist and cueing instructions . If th ould not have , he/she w probing questions is nurse had not asked recei ved enough information to make an accurate assessment of the actual assist ance Mr. C received. . oded 02, Substantial/maximal assistance Coding: GG0170E would be c provides more than half of the effort to complete the activity of The helper Rationale: . -to-chair transfer Chair/bed 60 October 2018 Page GG-

358 CMS’s Manual CH 3: MDS Items [ GG] RAI Version 3.0 Mobili ty (3 -day assessment period) GG0170: Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) 5. Toilet transfer: Example of a probing conversation between a nurse deter mining the resident’s score and a certified nursing assistant regarding a resident’s toilet transfer assessment: Nurse: “ I understand that Mrs. M usually uses a wheelchair to get to her toilet. Please describe how Mrs. M he move from ow does s . H moves from her wheelchair to the toilet sitting in a wheelchair to sitting on the toilet ?” “ It is hard for her, but she does it with my help.” Certified nursing assistant: Nurse: “Can you describe the amount of help in more detail?” Certified nursing assistant: “I have to give her a bit of a lift using a gait belt to get her to stand and then remind her to reach for the toilet grab bar while she pivots to the toilet. Sometimes, I have to remind her to take a step while she pivots to or from the toilet, but she does most of the effort herself .” In this exa mple, the nurse inquired specifically about how Mrs. M moves from sitting in a wheelchair to sitting on the toilet. The nurse s pecifical ly as ked about instructions and probing questions not asked ould not have , he/she w If this nurse had physical assist ance. ved enough information to make an accurate assessment of the actual ance Mrs. M assist recei received. Coding: oded 03, Partial/moderate assistance. GG0170F would be c Rationale: The certified nursing assistant provides less than half the effort to complete this activity. 6. Walk 50 feet with two turns: Example of a probing conversation between a nurse deter mining a resident’s score for walking 50 feet with two turns a nd a certified nursing assistant resident’s walking ability : regarding the Nurse: “ How much help does Mr. T need to walk 50 feet and make two turns once he is standing? ” Certified nursing assistant: “ He needs help to do that .” Nurse: “ How much help does he need?” Certified nursing assistant: “ He walks about 50 feet with one of us holding onto the gait belt and another person following closely with a wheelchair in case he needs to sit down.” mple, the nurse inquired specifically about how Mr . T walks 50 feet and makes In this exa ance. ked about physical assist not asked If this nurse had two turns. The nurse as probing questions , he/she w ould not have rece ived enough information to make an accurate assessment of the actual assist ance Mr . T received. Coding: GG01 70 J would be c oded 01, Dependent. two helpers to complete this activity Mr. T requires Rationale: . 61 October 2018 Page GG-

359 RAI CMS’s CH 3: MDS Items [ GG] Version 3.0 Manual GG0170: Mobili ty (3 -day assessment period) Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) mining a resident’s 7. Walk 150 feet: Example of a probing conversation between a nurse deter score for walking 150 feet a nd a certified nursing assistant regarding the resident’s walking ability : Nurse: escribe how Mrs. D walks 150 feet in the corridor once she is standing. ” “ Please d Certified nursing assistant: “She uses a walker and some help .” Nurse: “She uses a walker and how much instructions or physical help does she need?” “I have to support her b Certified nursing assistant: y holding onto the gait belt that is around her waist so that she doesn’t fall. She does push the walker forward most of the time.” Nurse: “Do you help with more than or less than half the effort?” Certified nursing assistant: “ I have to hold onto her belt firmly when she walks because she frequently loses her balance when taking steps. Her balance gets worse the further I help her with more I would say she walks , but she is very motivated to keep walking. than half the effort.” about how Mrs. D se inquired specifically mple, the nur In this exa walks 150 feet. The nurse probing asked about instructions and physical ance. If this nurse had not asked assist questions , he/she w ould not have rece ived enough information to make an accurate assessment of the actual received. assist ance Mrs. D Coding: GG0170K would be coded 02, Substantial/maximal a ssis tance . that is more than half provides trunk support Rationale: The certified nursing assistant the effort as Mrs. D walks 150 feet . nurse Wheel 50 feet with two turns: Example of a probing conversation between a 8. nd a certified nursing deter mining a resident’s score for wheel 50 feet with two turns a regarding the resident’s mobility : assistant “ I understand that Ms. R uses a manual wheelchair. Describe to me how Ms. R Nurse: herself 50 feet and makes two turns wheels once she is seated in the wheelchair .” Certified nursing assistant: “She wheels herself .” without any instructions or physical help?” “She wheels herself Nurse: “ Well yes, she needs help to get around turns, so I have to Certified nursing assistant: .” I do, she wheels herself once help her and set her on a straight path, but 62 October 2018 Page GG-

360 CMS’s Version 3.0 CH 3: MDS Items [ GG] RAI Manual Mobili -day assessment period) GG0170: ty (3 tart/End of Medicare Part A Stay) (cont.) Admission/Discharge (S In this exa mple, the nurse inquired specifically about how Ms. R wheels 50 feet with two turns. The nurse as ked about instructions and physical assist ance. If this nurse had not asked probing questions ould not have rece ived enough information to make an accurate , he/she w assessment of the actual assist ance Ms. R received. Coding: GG01 70R would be coded 03, Partial/Moderate assist ance . Rationale: The certified nursing assistant must physically push the wheelchair at some points of the activity; however, the helper does less than half of the activity for the resident. a nurse Example of a probing conversation between Wheel 150 feet: mining a deter 9. resident’s nd a certified nursing assistant regarding the resident’s et a score for wheel 150 fe : mobility “ I understand that Mr. G usually uses an electric scooter for longer distances. Nurse: Once he is seated in the scooter, does he need any help to mobilize himself at least 150 feet ?” Certified nursing assistant: “ He drives the scooter himself ... he’s very slow .” Nurse: “ He uses the scooter himself without any instructions or physical help?” ” Certified nursing assistant: “ That is correct. mple, the nurse In this exa about how Mr. G uses an electric scooter to inquired specifically ould not mobilize himself 150 feet. not asked probing questions , he/she w If this nurse had have recei ved enough information to make an accurate assessment of the actual assist ance received. Mr. G Coding: GG01 70S would be c oded 06, Independent . in the corridor for at least 150 feet without Rationale: navigates The resident assistance. 63 October 2018 Page GG-

361 RAI CMS’s CH 3: MDS Items [ GG] Manual Version 3.0 -day assessment period) ty (3 GG0170: M obili Admission/Discharge (Start/End of Medicare Part A Stay) (cont.) Discharge Goals: Coding Tips Discharge goals are coded with each Admission (Start of SNF PPS Stay) assessment. • For the SNF QRP, a minimum of one self-care or mobility goal must be coded. However, facilities may choose to complete more than one self-care or mobility discharge goal. Code the resident’s discharge goal(s) using the six-point scale. Use of “activity not attempted” codes (07, 09, 10, and 88) is permissible to code discharge goal(s). The use of a dash is permissible for any remaining self-care or mobility goals that were not coded. Using the dash in this allowed instance after the coding of at least one goal does not affect APU determination . clinicians can establish a resident’s discharge goal(s) at the time of qualified Licensed • admission based on the resident’s prior medical condition, Admission assessment self- care and mobility status, discussions with the resident and family, professional judgment, the profession’s practice standards, expected treatments, resident motivation to improve, anticipated length of stay, and the resident’s discharge plan. Goals should be established as part of the resident’s care plan. • If the performance of an activity was coded 88, Not attempted due to medical condition or safety concerns, during the Admission assessment, a discharge goal may be coded ity by using the six-point scale if the resident is expected to be able to perform the activ discharge. 64 October 20 18 Page GG-

362 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: SECTION H: BLADDER AND BOWEL formation on the use of bowel and The intent of th e ite ms in th Intent: ction is to gather in is se bladder appliances, the use of and response to urinary toileting progra ms, urinary and bowel t continence, bowel training progra ms, and bowel patterns . Each residen t wh o is incon tine nt or a risk of developing incontinence should be ident , assessed , an d provided wit h individualized ified treat ment ( medications, non-m edicinal treat ments and/or devices) and services to achieve or maintain as norm al elimina tion function as possible. H0100: Appliances Item Rationale DEFINITIONS of Life -related Health Quality INDWELLING CATHETER use and It is important to know what appliances are in • that is maintained A catheter rationale for such use. the history and the bladder for within the External catheters should fit well and be comfortable, • purpose of continuous drainage of urine. minim ize leakage, maintain skin integrity, and ote prom resi gnity. dent di SUPRAPUBIC is there unless Indwelling catheters should not be used • CATHETER edical justification. Assessment valid m should include An indwelling catheter is that directly by a urologist placed indwelling of an benefits and consideration of the risk into the bladder the through anti cipated duration of use , and cath eter, the abdomen. type of This considerati on of complicat ions resulting the use of from frequently used catheter is an indwelling catheter. mplications can include an Co there is when an obstruction e increased risk of urinary tract infection , blockage of th the flow through of urine d bypassin catheter wit h assoc iate g of urine, expulsion of urethra. the catheter, pain, discomfort, and bleeding. TUBE NEPHROSTOMY periostom • mies Osto of al skin) should be free (and inserted A catheter through redness d breakdown. , tendern ess , excoriation , an the skin kidney the into in and Appliances should fit well, be comfortable, individuals with an mote resident dignity. pro ureter the abnormality of (the that fibromuscular tube Planning for Care from urine carries the kidney bladder) or the to the • Care planning should include interventions that are bladder. ize consistent with the resident’s goals and minim appliance use. ns associated with complicatio October 2018 Page H-1

363 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] DEFINITIONS (cont.) H0100: Appliances CATHETER EXTERNAL Care planning should be based on an assessment and • shaft attached Device to the evaluation of the resident’s history, physical like a condom penis of the examination, physician orders, progress notes, nurses’ or a receptacle for males notes and flow sheets, pharmacy and lab reports, voiding around the pouch that fits history, resident’s overall condition, risk factors and females and for labia majora information about the resident’s continence status, connected to a drainage bag. rs related to catheter status, environmental facto OSTOMY continence programs, and the resident’s response to type of surgically created Any catheter/continence services. of the opening gastrointestinal or Assessment Steps for genitourinary for tract resence of any urinary o r 1. Exa mine the resident to note the p discharge of body waste. bowel appliances. UROSTOMY 2. Review the m edical record, including bladder and bowel for the urinary A stoma or past use of urinary entation of current for docum records, system used in cases where l appliances. or bowe of urine long -term drainage through and the bladder Coding Instructions e.g., is not possible, urethra to each next Check time at any in the appliance that was used after extensive surgery or in case of obstruction. the past the 7 days. Select none of if none of above appliances A-D s. in the past 7 day used were ILEOSTOMY that A stoma been has catheter indwelling , 100A H0 • (including suprapubic by bringing constructed the nephrostomy tube) and catheter intestine of small loop end or H0 , 100B • heter cat external out onto (the ileum) the of the skin. surface • H0 ostomy (including urostomy, ileostomy, and 100C, colostomy) COLOSTOMY has that A stoma been H0 • 100D , inter mittent c atheterizati on constructed by connecting a none of the above H0 • , 100Z colon part onto of the the abdominal anterior wall. Coding Tips and Special Populations INTERMITTENT • catheters and nephrostomy tubes should be Suprapubic CATHETERIZATION coded (H0100A) only and not an indwelling catheter as Insertion and removal of a my (H0100C). as an osto catheter through the urethra drainage. bladder for uches Condom catheters (males) and external urinary po • (females) are often used interm ittently or at night only; these should be coded as external catheters. appliances this • Do not code gastrostomies or other feeding ostom ies in se ction. Only us ed for eli mination are coded here. urine • Do not include one- tim e catheterization for period as speci men during look- back inter mittent catheterization. H-2 Page October 2018

364 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] (cont.) H0100: Appliances Self -catheterizations that are performed by the resident in the facility should be coded as • -catheterizations using clean intermittent catheterization (H0100D). This includes self technique. H0200: Urinary Toileting Program Rationale Item -related of Life Health Quality • An individualized, resident- centered toileting program m ay decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence. f to provide more • mining the type of urinary incontinence ca n allo w staf Deter individualized progra mm ing or interventions to enhance the resident’s quality of life and functional status. mentia) • Many incontinent residents (including those with de respond to a toileting program, especially during the day. Planning for Care t receives appropriate treat the residen ensuring that ment and services to • The steps to ward rest ore as possible are much bladder function as experiencing mining if — currently deter so me level of incontinence or is the resident is at risk of developing urinary incontinence; — completing an accurate, thorough assess ment of factors that m ay predispose the residen t to having urinary incontinence; and modifying — implementing appropriate, individualized interventions and them as appropriate. If the toileting program or bladder retraining leads to a decrease or resolution of • incontinence, the program should be m aintained. • Research has shown that one quarter to one th ird of residents will have a decrea se or resolution of incontinence in response to a toileting program. er If incontin ence is n • ith a toileting tr ial, co nsid er whether oth ot decreased or resolved w sent. sible or treatable causes are pre rever Page October 2018 H-3

365 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: H0200: Urinary Toileting Program (cont.) Res specialize in diagnosing and • idents may need to be referred to practitioners who ffect bladder function. conditions th ating tre at a • Residents who do not respond to a toileting trial and for whom other reversible or ment (such as checking anage treatable causes are n ot found should receive supportive m his or her and if needed the resident providing good brief for incontinence and changing skin care). Assessment: H0200A, Trial of a DEFINITIONS Steps for am Progr Toileting BLADDER REHABILITATION/ The look-ba ck period for this is since item the most recent RETRAINING BLADDER or since urinary incontinence was admission/entry or reentry that technique A behavioral noted within the facility. first resident the requires to resist sensation of the or inhibit edical dence of a trial the m Review for evi 1. of an record desire to strong (the urgency individualized, resident- g program. A centered toiletin to postpone urinate), or delay trial should include observations of at least 3 days toileting voiding, and to urinate d of of toileting patterns with prom ptin g to toile t an according to a timetable or voiding diary. a bladder record in sults ding re recor to the urge to rather than Toileting progra ms may have different names, e.g., habit void. training/scheduled voiding, bladder rehabilitation/bladder VOIDING PROMPTED retraining. Prompted includes voiding Review records of voiding patterns (such as frequency, 2. with monitoring regular (1) ightti me or daytime, quality of stream ) volume, duration, n encouragement to report over several cing hose who are experien days for t (2) status, continence a using incontinence. schedule the prompting and rin Voiding records help detect u 3. erns als or interv ary patt to toilet, and (3) resident te providing care between in continenc e episodes and f acilita feedback praise and positive is when the resident episodes. to avoid or reduce the frequency of to and attempts continent 4. Simply tracking continence status using a bladder record or toilet. should not be con voiding diary a trial of an sidered . individualized, resident -cent ered t oileting progr am HABIT TRAINING/ ted Residents should be reevalua whenever th a change ere is 5. SCHEDULED VOIDING sical ability, or urinary tract function. in cognition, phy A behavior technique that Nursing hom e staff must use clinical judg ment to deter mine at toileting scheduled calls for ap when it is propri ate to r eevalu ate a r esiden t’s ability to on a intervals regular the to match planned basis ileting trial was a toil in eting trial or, tic ipate if the to par habits or resident’s voiding for a trial of a different toileting unsuccessful, the need needs. m. progra CHECK AND CHANGE Involves checking the status at resident’s dry/wet regular intervals and using and devices incontinence products. H-4 Page October 2018

366 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] H0200: Urinary Toileting Program (cont.) Assessment : H0200B, Response to Trial Toileting for Steps Program Review the resident’s responses as recorded during the toileting tria l, noting any change in 1. ber of incontinence episodes or degree of wetness the resident experiences. the num Steps Assessment: H0200C, Current Toileting Program or Trial for dence of a toileting program being used to m the m edical record for evi 1. anage Review incontinence during the 7-day look-back period. Note the number of days during the look- back period that the toileting program was implemented or carried out. 2. Look for documentation in the m edical record s howing that the following three requirem ents have been met: oile ting program entation of an individualized, resident -spe • implem that was based cific t on an assess ment of the resident’s unique voidin g pattern ; • evidence that the individualized pro gram was communicated to staff and the re siden t (as d a appropriate) verbally an, flo w records , an through a care pl writte n report ; and and • notations of the resident’s response to the toileting program and subsequent evaluations, as needed . 3. Guidance for developing a toileting program may be obtained from sources found in Appendi x C. Toileting Trial Program Coding Instructions H0200A, • e 0, no: if for any reason the resident did not undergo a toileting trial. This includes Cod ts w or without toile ntinent of urine with residen ting assistance, or who use a ho are co per my, as well as residen ts who prefer not to participate in a trial. manent catheter or osto Skip to Uri nary Continence item (H0300). • underwent a e 1, y for residents Cod es: trial of an individualized, resident -centered who toileting program at l east once since the most recent admission/entry or reentry or since urinary incontinence was first noted within the facility . • Code 9, unable to determine: if a trial if records cannot be obtained to deter mine has been attempted. If code 9, skip H0200B and go to H0200C, toileting program Current . l Toileting Program or Tria Coding H0200B, Toileting Program Trial Response Instructions • Code 0, no improv ement: if the frequency of resident’s urinary incontinence did not decrea se during the toileting tr ial. e 1, d • Cod ecreased wetness : if the resident’s urinary incontinence frequency decreased, mained incontinent. There is no quantitative definition of but the resident re improvement. However, the improvement should be clinically m eaningful —for example, having at least one less incontinent void per day than before the toileting program wa s ented. implem Page October 2018 H-5

367 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: H0200: Urinary Toileting Program (cont.) Code 2, c ompl etely dry (cont inent): if the resi dent be comes complet ely contin ent • ting tria l. ( For resi dents of urine, with no episodes of urinary incontinence during th e toile one toileting stay, trial during their have undergone more than use the most who program mplete this ite m.) rece nt trial to co • e 9, u nabl e to d etermin e or tria l in Cod gress : if the respo nse to th e toileting pro trial cannot be det ation cannot be found or because the trial is still ermined because inform in progress. Coding H0200C, Current Toileting Program Instructions Cod e 0, no: if an individualized resident -centered • program (i.e., pro mpted toileting voiding, scheduled toileting, or bladder training) is used less than 4 days of the 7-day back period to m anage look- s urinary continence. the resident’ • day during 4 or more days of the 7- anaged, are being m Cod e 1, y es: for residents who look-back period, with som matic toileting program (i.e., bladder yste e type of s rehabilitation/bladder retraining, prompted voiding, habit training/scheduled voiding). me residents prefer to not be awakened to to ile t. If that resident, however, is on a So toileting program during the day, code “yes.” Tips for Coding H0200A -C fer to • Toileting ( or trial to ile tin g) progra ms re a sp ecific ap pro ach that is organized, e’s planned, documented, monitored, and evaluated that is consistent with the nursing hom d curren t standard policies and procedures an rogram does not cti ce. A toileting p s of pra refer to ly trac king continence status, — simp — changing pads or wet gar ments, and — random assistance with toileting or hygiene. • For a resident currently undergoing a trial of a toile ting progra m, — H0200A would be coded 1, yes, — H0200B would be coded 9, unable to determine or trial in progress , and coded 1, yes. — H0200C would be Page October 2018 H-6

368 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] H0200: Urinary Toileting Program (cont.) Example s me Mrs. has Alzhei H. r’s disease. She is dependent on th e staf f for 1. a diagnosis of advanced tive ability to void in the toilet or other appropriate her ADLs, does not have the cogni ptacle, rece is totally incontinent. Her voiding assessm ent/diary indicates no pattern to her and w the incontinence. Her care plan states that due to incontinence, staf f should follo total her facility standard policy for incontinence, whic h is to check an d change ever y 2 hours while awake and apply a superabsorbent brief at bedtime so as not to disturb her sleep. Codi ng coded as 0, no . H0200B and H0200C would be skipped. : H0200A would be assessm ionale: Rat this resident’s voiding Based ent/diar y, there was no patt ern to on her incontinence. Therefore, H0200A would be coded as 0, no. Due to total incontinence a toileting is not appropriate for this resident. Since H0200A is coded 0, no, skip program to H0300, Urinar y Continenc e. 2. Mr. M., who has a diagnosis of congestive heart failure (CHF) and a history of left -sided hem iplegia from a previous stroke, has had an in crease in u rin ary inco ntin ence. The team has evaluated has him for a reversible cause of the incontinence and his voiding pattern assessed using a voiding assessment/diary. After com mined that ment, it was deter pleting the assess incontinence episodes could be reduced. A plan was developed and implem ented that called ter receiving his 8 a. m. diuretic, then every 3 hours until for toileting every hour for 4 hours af e at 9 p. m. The team has communicated this approach to the resid ent and the care team bedtim these interventions in has pl aced the ca and re plan . The team will r eeval uate t he re sid ent’s response to after 1 month an d adjus t as needed. the plan Coding: H0200A would be coded as 1, yes . coded as 9, unable to determine or trial in H0200B would be . progress H0200C would be coded as 1, current toileting program or trial. sessm de on this resident’s voiding as Based ent/diar y, it was term ined that ionale: Rat this resident could benefit from a toileting program. Therefore H0200A is coded as 1, mined that incon yes. Based on the assess ment it was deter tin ence episo des could be reduced, H0200B is coded as 9, unable to deter mine or tr ial in progress. An therefore the resident has been developed, implem ented, and com municated to individualized plan or trial. and staff, therefore H0200C is coded as 1, current toileting program Page October 2018 H-7

369 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: H0300: Urinary Continence Rationale Item DEFINITIONS of Life Health Quality -related URIN ARY EN INCONTIN CE Incontinence can • of uri ne. The in ry loss volunta ere with particip ation in activities, — interf CON TINEN CE and be socially embarrassing — lead increased to s v oid Any that occur feelings of dependency, arily volunt esu , or as lt of the r ting, assist ed ted toile promp increase risk of long- tio nalization, — term institu toile duled sche or ting, d breakdown, s an n rashe k of ski e ris increas — toilet ing. infections, and k of repeated urinary tract increase ris — of f increase the risk — ilet a to reach to mpts alls fro resulting ries inju and m atte unassis ted. Planni ng for Care inim m ized be resolved by For • any or m residents, incontinence can — identifying and treating underlying pot entiall y reversibl e causes , including impaction, fecal and constipation fection, in urinary tract side effects, medication or recent onset of and immobility (especially among those with the new incontinence); co mmodes, bedpans, and — eli minating environm ental physical barr iers to accessing urinals ; and — bladder retraining, pro mpted voiding, or scheduled toileting. who • For residents whose incontinence does not hav e a reversibl e cause and do not respond to pro mpted voiding, or scheduled toileting, the interdisciplinary team retraining, should establish a plan to m dryness and m inim ize exposure to urine. aintain skin for Assessment Steps edical record for bladder or incontinence records or flow sheets, nursing 1. Review the m assessments and progress notes, physician history, and physical examination. 2. capable of reliably reporting his or her continence. Speak if he or she is dent the resi view Inter with fa ce. on continen report not able to dent is mily members or significant others if the resi 3. bout incon ence tin ts a hif all s dent on he resi nely work with t o routi f wh e staf t car k direc As episodes. H-8 Page October 2018

370 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: (cont.) H0300: Urinary Continence Instructions Coding e 0, al resident has s contine nt: if throughout the 7-day look- back period the way • Cod ence. episodes of incontin been continent of urine, without any • ccasionally Cod nent : if during the 7-day look- back period the e 1, o inconti t was isodes. This includes incontinence of any amount residen incontinent less than 7 ep ents, nt to dampen undergarm or pads during day time or nighttim e. of urine sufficie briefs, Code 2, frequen tly i ncontinen t: if during the 7-day look- • period, the resident back was incontinent of urine during seven or more episodes but had at least one continent in cludes ntinence of any amount of urine, daytime and nighttim e. void. This inco • Code 3, always incontinent: back period, the resident had if during the 7-day look- no continent voids. Cod e 9, not ra ted : if during the 7-day look- • period the resident had an indwelling back bladder catheter, catheter, ostomy, or no urine output (e.g., is on chronic dialysis condom no urine output e 7 r the entir with days. ) fo Tips and Special Populations Coding level de continence • on based If inter mitte nt cat het erization is used to dra in the bladder, co continen heterizations. ce between cat Examples An ny year -old fe male resident has had longstanding stress- type incontinence for ma 1. 86- years. When she has an upper respiratory in fectio n an d is coughing, she involuntarily loses been urine. However, 7-day look- back period, the resident has during the current free of respiratory sy mpto ms and has not had an episode of incontinence. . Coding: H0300 would be coded 0, always continent sh e Rat ionale: Even though the resident has known inter mittent stre ss inco nt inence, was continent during the current back period. 7-day look- 2. A resident w ith multi- infarct dem entia is incontinent of urine on three occasions on day one of observation, continent of urine in response to toileting on days two and three, and has one urinary inc ontinence episode during each of the nights of days four, five, six, and seven of the look-back period. Coding: H0300 would be coded as 2, frequently incontinent . Rationale: The resident had seven docu mented episodes of urinary incontinence over the look-back period. The criterion for “frequent” incontinence has been set at seven or period with at least one continent void. more episodes over the 7-day look- back Page October 2018 H-9

371 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: (cont.) H0300: Urinary Continence A resident w ith Parkinson’s disease is severely 3. and cannot be transferred to a immobile, toilet. He is unable to use a urinal and is managed by adult brief s an d bed pad s that are back period. regularly He did not have a contin ent voi d durin g th e 7-day look- changed. Coding: H0300 would be coded as 3, always incontinent . resident has due to cannot be toileted no urinary continent episodes and Rationale: The anaged by a check and change in m severe disability or discomfort. Incontinence is protocol. 4. A resident had one continent urinary void during the 7-day look-back period, after the to the toilet and helped with clothing. All other voids were nursing assistant as sisted him incontinent. H0300 would . Coding: coded as 2, frequently incontinent be one conti nen The resident had at least Rationale: t voi d durin g the look -bac k period. The sion. nto the coding d eci reason for the co ntin ence does n ot enter i H0400: Bowel Continence Note: There are images imbedded in this manual and if you are using a screen reader to access the content contained in the manual you should refer to the data item set to review the refe renced information. Item Rationale Health -related Quality of Life Incontinence can • interf ere with particip ation in activities, — — be socially embarrassing and lead to increased feeling s of dependency, — increase risk of long- term institu tio nalization, — increas e ris k of ski n rashe s an d breakdown, and of falls and — increase the risk mpts to reach a toilet om atte inju ries re sulting fr unassisted. Planning for Care • For m residents, incontinence can be resolved or m inim ized by any y reversibl — identifying and managing underlying pote ntiall e causes , including medication side effects, constipation and fecal impaction, and immobility (especially among those with the new or recent onset of incontinence); and mmodes, bedpans, and co — eli minating environm ental physical barr iers to accessing urinals. H- 10 October 2018 Page

372 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] H0400: Bowel Continence (cont.) For residents whose incontinence does not hav e a reversibl e cause and who do not • progra ms, the interdisc iplinary team should establish a plan to retraining respond to maintain skin dryness and minimize exposure to stool. for Assessment Steps 1. the m edical record for bowel records and incontinence flow sheets, nursing Review and examination. assessments and progress notes, physician history physical Inter 2. the resi dent if he or she is capable of reli ably reporting his or her bowel habits. view Speak with fam on ily memb ers or significant o ther if the re sident is unable to report ce. continen he resi As k direc t car e staf f wh o routi nely work with t bout incon dent on all s hif ts a 3. tin ence episodes. Coding Instructions has • Cod e 0, al way s contine nt: if during the 7- day look- back period the resident ents, without any l movem been continent of bowel on all occasions of bowe episodes of incontinence. • Cod e 1, o ccasionally inconti nent i f during the 7-day look- back period the : resident was incontinent of stool once. This includes incontinence of any amount of stool day or night. • Code 2, frequen tly i ncontinen t: if during the 7-day look- back period, the resident was incontinent of bowel more than once, but had at least one continent bowel movement. This includes incontinence of any amount of stool day or night. the 7-day look- resident w as • Cod e 3, al way s inc ontin ent: i f during back period, the me nts and had no continent bowel movem ents. bowel move incontinent of bowel for all ted Cod e 9, not ra had : i f during the 7-day look- back period the resident • an ostomy or did not have a bowel movement for the entire 7 days. (Note that these residents should be ation checked im paction and evaluated for co nstip for fecal .) Coding Tips and Special Populations y caus rom an e (including • Bowe l incontinence precipitate d by loose stools or diarrhe a f laxatives) would count as incontinence. H- 11 October 2018 Page

373 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: H0500: Bowel Toileting Program Item Rationale Quality Health of Life -related ay decrease or prevent bo matically i ileti A syste m mplemented bowel to wel • ng program incontinence, minimizing or avoiding the negative consequences of incontinence. Many incontinent residents • a bowel toileting progra m, es pecially during the respond to day. Planning for Care • If the bowel toileting prog leads to a decrease or resolution of incontinence, the ram program should be m aintained. If bowel incontinence is • or res olv ed with a b owel toileting trial, con sid er not decreased whether oth versible or treata ble causes are p resent. er re other reversible or • Residents who do not respond to a bowel toileting trial and for whom treatable causes are n ot found should receive supportive ma nage ment (such as a regular check and change program with good skin care). Residents w ith a colostomy or colectom y ma y ne • diet monitored to pro mote ed their healthy bo wel eli mination and careful monitor ing of ski n to preven t sk in ir ritation and breakdown. • the consider assessing to ay want When developing a toileting program the provider m and resident adequate fiber in the diet, ex ercise, intake, scheduled tim es for adequate fluid to attempt bowel mov em ent (New man, 2009). Steps for Assessment dence of a bow 1. R eview the m edical record for evi el toileting program being used to m anage bowel incontinence during the 7-day look-back period. howing that 2. Look for documentation in the m edical record s ents the following three requirem have been met: • implem entation of an individualized, resid ent- specific bowel toileting program based on an assess ment of the resident’s unique bowel pattern; pro t (as siden re idence that the individualized gram was communicated to staff and the ev • appropriate) verbally and through a care plan, flow records, verbal and a written report; and response to the toileting program and subsequent evaluations, • notations of the resident’s as needed. H- 12 October 2018 Page

374 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [H] H0500: Bowel Toileting Program (cont.) Instructions Coding Cod e 0, no: if the resident • toileting pr ogram targeted specifically is not currently on a at managing bowel continence. • toile Cod es: i f the resident is currently on a e 1, y ting program targeted specifically at managing bowel continence. H0600: Bowel Patterns Rationale Item DEFINITION of Life -related Quality Health CONSTIPATION has two or resident If the Severe constipation can cause abdominal pain, • movements bowel fewer anorexia, vomiting, bowel incontinence, and delirium. 7- during the -back look day If unaddressed, constipation can lead to fecal impaction. • bowel or if for period most movements their is hard stool Planning for Care to pass them difficult for and matter what the (no sidents who may need further re ies item identif This • of bowel frequency evaluatio n of an d interventio n on bowel habits. movements). • Constipation m ay be a manifestation of serious conditions such as — dehydration due to a m edical condition or i nadequat e acces s to an d intak e of fluid, and — side effects of medications. Steps for Assessment DEFINITION Review the m edical record for bowel records or flow 1. FECAL IMPACTION sheets, n ursing assessments and progress notes, physician A large mass of dry, hard mine if deter to ination physical and history exam the in the stool develop can that resident had problems with constipation during the 7- has due to chronic rectum day look-back period. constipation. This mass may Residents w ho are capable of reli ably reporting their 2. hard is resident the that be so . Speak continence and bowel habits shoul d be interviewed to move unable it from the the r with fam t o fican mbers or signi ily me t is esiden thers if stool Watery rectum. from on bowel habits. report unable to bowel higher or in the irritation from impaction the with routinely work aff who care st direct Ask the resident 3. may the move around mass about problems with constipation. on all shifts and leak out, causing soiling, often a fecal of a sign impaction. October 2018 H- 13 Page

375 CMS’s RAI Version 3.0 Manual MDS Items [H] CH 3: H0600: Bowel Patterns (cont.) Coding Instructions e 0, no: e 7-day look- of constipation durin • Cod back if the resident shows no signs g th period. • Cod e 1, y es: if the resident shows signs of constipation during the 7-day look- back period. Tips Populations Special Coding and Fecal is not synonymous im paction • ati on. Fecal im paction is caused by chronic constip with constipation. H- 14 October 2018 Page

376 CMS’s RAI Version 3.0 Manual MDS Items [I] CH 3: SECTION I: ACTIVE DIAGNOSES relationship to Intent: The items in this section are intended to code diseases that have a direct the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring , or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident’s current health status. I0020: Indicate the resident’s primary medical condition category Item Rationale Health -related Quality of Life Disease processes can have a significant adverse effect on residents’ functional • improvement. Planning for Care • This item identifies the primary medical condition category that resulted in the resident’s admission to the facility and that influences the resident’s functional outcomes. Steps for Assessment 1. Review the documentation in the medical record to identify the resident’s primary medical condition associated with admission to the facility. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available. Coding Instructions Complete only if A0310B = 01 Enter the code that represents the primary medical condition that resulted in the resident’s • admission. If codes 1–13 do not apply, use code 14, “Other Medical Condition,” and I0020A. proceed to Page October 2018 I-1

377 CMS’s RAI Version 3.0 Manual MDS Items [I] CH 3: I0020: Indicate the resident’s primary medical condition category (cont.) • Include the primary medical condition coded in this item in Section I: Active Diagnoses in the last 7 days. — Code 01 , Stroke , if the resident’s primary medical condition category is due to stroke. Examples include ischemic stroke, subarachnoid hemorrhage, cerebral vascular accident (CVA), and other cerebrovascular disease. — Code 02 , Non- Traumatic Brain Dysfunction, if the resident’s primary medical traumatic brain dysfunction. Examples include Alzheimer’s condition category is non- disease, dementia with or without behavioral disturbance, malignant neoplasm of brain, and anoxic brain damage. — Code 03 , Traumatic Brain Dysf unction, if the resident’s primary medical condition category is traumatic brain dysfunction. Examples include traumatic brain injury, severe concussion, and cerebral laceration and contusion. — , Non- Code 04 Traumatic Spinal Cord Dysfunction, if the resident ’s primary medical condition category is non- traumatic spinal cord injury. Examples include spondylosis with myelopathy, transverse myelitis, spinal cord lesion due to spinal stenosis, and spinal cord les ion due to dissection of aorta. if the resident’s primary medical , — Code 05, Traumatic Spinal Cord Dysfunction condition category is due to traumatic spinal cord dysfunction. Examples include paraplegia and quadriplegia following trauma. Code 06 , Progressive Neurological Conditions , if the resident’s primary — medical condition category is a progressive neurological condition. Examples include multiple sclerosis and Parkinson’s disease. if the resident’s primary medical , Code 07 , Other Neurological Conditions — condition category is other neurological condition. Examples include cerebral palsy, polyneuropathy, and myasthenia gravis. Code 08 , Amputation, if the resident’s primary medical condition category is an — amputation. An example is acquired absence of limb. — , Code 09 , Hip and Knee Replacement if the resident’s primary medical condition category is due to a hip or knee replacement. An example is total knee replacement. If hip replacement is secondary to hip fracture, code as fracture. Fractures and Other Multiple Trauma, Code 10, if the resident’s prim ary — medical condition category is fractures and other multiple trauma. Examples include hip fracture, pelvic fracture, and fracture of tibia and fibula. — Code 11, Other Orthopedic Conditions , if the resident’s primary medical condition category is other orthopedic condition. An example is unspecified disorders of joint. Debility, Cardiorespiratory Conditions if the resident’s primary — Code 12, , medical condition category is debility or a cardiorespiratory condition. Examples include monary disease (COPD), asthma, and other malaise and fatigue. chronic obstructive pul Page October 2018 I-2

378 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I0020: Indicate the resident’s primary medical condition category (cont.) Code 13, Medically Complex Conditions , — if the resident’s primary medical condition category is a medically complex condition. Examples include diabetes, pneumonia, chronic kidney disease, open wounds, pressure ulcer/injury, infection, and disorders of fluid, electrolyte, and acid-base balance. if the resident’s primary medical condition — Code 14, Other Medical Condition, category is not one of the listed categories. Enter the International Classification of Diseases (ICD) code, including the decimal, in I0200A. If item I0020 is coded 1–13, do not complete I0020A. Examples of Primary Med ical Condition year Ms. K is a 67- 1. -old female with a history of Alzheimer’s dementia and diabetes who is admitted after a stroke. The diagnosis of stroke, as well as the history of Alzheimer’s dementia and diabetes, is documented in Ms. K’s history and physical by the adm itting physician. Coding: I0020 would be coded 01, Stroke. Rationale: The physician’s history and physical documents the diagnosis stroke as the reason for Ms. K’s admission. Mrs. E is an 82- year -old female who was hospitalized for a hip fracture with subsequent 2. total hip replacement and is admitted for rehabilitation. The admitting physician documents Mrs. E’s primary medical condition as total hip replacement (THR) in her med ical record. The hip fracture resulting in the total hip replacement is also documented in the medical record in the discharge summary from the acute care hospital. Coding: I0020 would be coded 10, Fractures and Other Multiple Trauma. Rationale: Medical record documentation demonstrates that Mrs. E had a total hip replacement due to a hip fracture and required rehabilitation. Because she was admitted for rehabilitation as a result of the hip fracture and total hip replacement, 10, Fractures and Other Mrs. E’s primary medical co ndition category is Multiple Trauma. 3. Mrs. H is a 93- year -old female with a history of hypertension and chronic kidney disease who is admitted to the facility, where she will complete her course of intravenous (IV) antibiotics after an acute episode of urosepsis. The discharge diagnoses of urosepsis, chronic kidney disease, and hypertension are documented in the physician’s discharge summary from the acute care hospital and are incorporated into Mrs. H’s medical record. Coding: I00 20 would be coded 13, Medically Complex Conditions. The physician’s discharge summary from the acute care hospital Rationale: documents the need for IV antibiotics due to urosepsis as the reason for Mrs. H’s admission to the facility. Page October 2018 I-3

379 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] s I: Active Diagnoses in the Last 7 Day I-4 October 2018 Page

380 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) I-5 October 2018 Page

381 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) Item Rationale DEFINITIONS -related Quality of Life Health DIAGNOSES ACTIVE Disease processes can have a significant adverse • effect Physician -documented 60 days diagnoses in the last on an individual’s health status and quality of life. relationship direct have a that Planning for Care resident’s current to the cognitive status, functional • This section identifies active diseases and infections or behavior, mood status, that drive the current plan of care. medical treatments, nursing or risk monitoring, of death Steps for Assessment during day look -back the 7- period. There are two look-back periods for this section: FUNCTIONAL • back Diagnosis identification (Step 1) is a 60-day look- LIMITATIONS period. of range Loss of motion, • -day Diagnosis status: Active or Inactive (Step 2) is a 7 muscle contractures, look-back period (except for Item I2300 UTI, which fatigue, weakness, -day look-back period). does not use the active 7 decreased ability to perform ADLs, paresis, or paralysis. 1. The disease conditions in this section Identify diagnoses: MONITORING NURSING require nurse diagnosis (or by a -documented physician a includes Nursing Monitoring practitioner, physician assistant, or clinical nurse specialist by a monitoring clinical last 60 days. if allowable under state licensure laws) in the nurse (e.g., serial licensed Medical record sources for physician diagnoses include evaluations, pressure blood progress notes, the most recent history and physical, medication management, transfer documents, discharge summaries, diagnosis/ etc.). problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. • Although open communication regarding diagnostic information between the physician and other members of the interdisciplinary team is important, it is also essential that diagnoses communicated verbally be documented in the medical record by the physician to en sure follow-up. Diagnostic information , including past history obtained from family members and close • contacts , must also be documented in the medical record by the physician to ensure validity and follow-up. Determine whether diagnoses are active: 2. Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct to the resident’s current functional, cognitive, or mood or behavior status, relationship medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7- day look-back period, as these would be considered inactive diagnoses. I-6 Page October 2018

382 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] ive Diagnoses in the Last 7 Days (cont.) I: Act Item I2300 UTI, has specific coding criteria and does not use the active 7-day look- back. • -8 for specific coding instructions for Item I2300 UTI. Please refer to Page I Check the following information sources in the medical record for the last 7 days to • identify “active” diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor’s orders, consults and official diagnostic reports, and other sources as available. Coding Instructions Code diseases that have a documented diagnosis in the last 60 days and have a direct relat ionship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period (except Item I2300 UTI, which does not use the active diagnosis 7-day look- back. Please refer to Item I2300 UTI, Page I-8 for specific coding instructions). • Document active diagnoses on the MDS as follows: — Diagnoses are listed by major disease category: Cancer; Heart/Circulation; Gastrointestinal; Genitourinary; Infections; Metabolic; Musculoskeletal; Neurological; Nutritional; Psychiatric/Mood Disorder; Pulmonary ; and Vision. — Examples of diseases are included for some disease categories. Diseases to be coded in these categories are not meant to be limited to only those listed in the examples. , including those listed includes anemia of any etiology , I0200, Anemia For example, (e.g. , iron deficiency, pernicious, sickle cell). , aplastic • Check off each active disease. Check all that apply. • If a disease or condition is not specif ically listed, enter the diagnosis and ICD code in item I8000, Additional active diagnosis. • Computer specifications are written such that the ICD code should be automatically justified. The important element is to ensure that the ICD code’s decimal point is in its own box and should be right justified (aligned with the right margin so that any unused boxes and on the left.) • may be , a Z code If a n individual is receiving aftercare following a hospitalization des cover situations where a patient requires continued care for healing, assigned. Z co recovery, or long- term consequences of a disease when initial treatment for that disease , another diagnosis for the related has already been performed. When Z codes are used primary medical condition should be checked in items I0100–I7900 or entered in I8000. ICD -10-CM coding guidance with links to appendices can be found here: . https://www.cms.gov/Medicare/Coding/ICD10/index.html Cancer (with or without metastasis) • I0100, cancer Page October 2018 I-7

383 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Act ive Diagnoses in the Last 7 Days (cont.) Heart/Circulation • I0200, anemia (e. g., aplastic, iron deficiency, pernicious, sickle cell) • I0300, atrial fibrillation or other dysrhythmias (e. g., bradycardias, tachycardias) • I0400, coronary artery disease (CAD) (e.g ., angina, myocardial infarction, atherosclerotic heart disease [ASHD]) I0500, deep venous thrombosis (DVT), pulmonary embolus (PE), or pulmonary • thrombo- embolism (PTE) • I0600, heart failure (e.g ., congestive heart failure [CHF], pulmonary edema) • I0700, hypertension • I0800, orthostatic hypotension • I0900, peripheral vascular disease or peripheral arterial disease Gastrointestinal • I1100, cirr hosis e.g., esophageal, gastric, and gastroesophageal reflux disease (GERD) or ulcer ( • I1200, peptic ulcers) • ulcerative colitis or Crohn’s disease or inflammatory bowel disease I1300, Genitourinary I1400, benign prostatic hyperplasia (BPH) • • I1500, renal insufficiency, renal failure, or end -stage renal disease (ESRD) • I1550, neurogenic bladder • I1650, obstructive uropathy Infections • multidrug resistant organism (MDRO) I1700, • pneumonia I2000, I2100, septicemia • • I2200, tuberculosis • I2300, urinary tract infection (UTI) (last 30 days) I2400, viral hepatitis ( e.g., hepatitis A, B, C, D, and E) • • I2500, wound infection (other than foot) Metabolic diabetes mellitus (DM) (e I2900, .g., diabetic retinopathy, nephropathy, neuropathy) • Page October 2018 I-8

384 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) I3100, hyponatremia • I3200, hyperkalemia • I3300, hyperlipidemia (e.g., hypercholesterolemia) • I3400, • .g., hypothyroidism, hyperthyroidism, Hashimoto’s thyroid disorder (e thyroiditis) Musculoskeletal arthritis (e • I3700, , osteoarthritis, rheumatoid .g., degenerative joint disease [ DJD] arthritis [RA]) • I3800, osteoporosis • I3900, hip fracture (any hip fracture that has a relationship to current status, treatments, monitoring (e.g., subcapital fractures and fractures of the trochanter and femoral neck) • I4000, other fracture Neurological • I4200, Alzheimer’s disease • I4300, aphasia cerebral palsy I4400, • • I4500, cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke I4800, dementia (e.g -Body dementia; vascular or multi- infarct dementia; mixed ., Lewy • dementia; frontotemporal dementia, such as Pick’s disease; and dementia related to stroke, Parkinson’s disease or Creutzfeldt- Jakob diseases) • I4900, hemiplegia or hemiparesis • I5000, paraplegia • I5100, quadriplegia multiple • I5200, sclerosis (MS) • Huntington’s disease I5250, I5300, • Parkinson’s disease • I5350, Tourette’s syndrome • I5400, seizure disorder or epilepsy • I5500, traumatic brain injury (TBI) Nutritional • I5600, malnutrition (protein or calorie) or at risk for malnutrition Psychiatric/Mood Disorder anxiety disorder I5700, • Page October 2018 I-9

385 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) I5800, • depression (other than bipolar) • I5900, manic depression (bipolar disease) • I5950, psychotic disorder (other than schizophrenia) I6000, schizophrenia (e.g., schizoaffective and schizophreniform disorders) • • I6100, post- traumatic stress disorder (PTSD) Pulmonary I6200, • asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease (e.g., chronic bronchitis and restrictive lung diseases, such as asbestosis) • I6300, respiratory failure Vision I6500, cataracts, glaucoma, or macular degeneration • None of Above I7900, none of the above active diagnoses within the past 7 days • Other • I8000, additional active diagnoses Coding Tips The following indicators may assist assessors in determining whether a diagnosis should be coded as active in the MDS. • There may be specific documentation in the medical record by a physician, nurse practitioner, physician a ssistant, or clinical nurse specialist of active diagnosis. The physician may specifically indicate that a condition is active. Specific — documentation may be found in progress notes, most recent history and physical, ary, etc. transfer notes, hospital discharge summ — For example, the physician documents that the resident has inadequately controlled hypertension and will modify medications. This would be sufficient documentation of active disease and would require no additional confirmation. In the • absence of specific documentation that a disease is active, the following indicators may be used to confirm active disease: — Recent onset or acute exacerbation of the disease or condition indicated by a positive study, test or procedure, hospitalization for acute symptoms and/or recent change in therapy in the last 7 days . Examples of a recent onset or acute exacerbation include ray; hospitalization the following: new diagnosis of pneumonia indicated by chest X- for fractured hip; or a blood transfusion for a hematocrit of 24 . Sources may include radiological reports, hospital discharge summaries, doctor’s orders, etc. I- 10 October 2018 Page

386 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Di agnoses in the Last 7 Days (cont.) decompensated disease in the — Symptoms and abnormal signs indicating ongoing or last 7 days. For examp le, intermittent claudication (lower extremity pain on exertion) in conjunction with a diagnosis of peripheral vascular disease would indicate active disease. Sometimes signs and symptoms can be nonspecific and could be caused by , a symptom must be specifically attributed to the several disease processes. Therefore disease. For example, a productive cough would confirm a diagnosis of pneumonia if specifically noted as such by a physician. Sources may include radiological reports, nursing assessments and car e plans, progress notes, etc. — Listing a disease/diagnosis (e.g., arthritis) on the resident’s medical record problem list is not sufficient for determining active or inactive status. To determine if arthritis, iewer would check progress notes for example, is an “active” diagnosis, the rev (including the history and physical) during the 7- day look- back period for notation of treatment of symptoms of arthritis, doctor’s orders for medications for arthritis , and documentation of physical or other therapy for fu nctional limitations caused by arthritis. — Ongoing therapy with medications or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potentially severe side medication indicates active disease if that medication is . A effects in the last 7 days prescribed to manage an ongoing condition that requires monitoring or is prescribed to decrease active symptoms associated with a condition. This includes medications used to limit disease progression and complications. If a medication is prescribed for a condition that requires regular staff monitoring of the drug’s effect on that condition (therapeutic efficacy), then the prescription of the medication would indicate active disease. • It is expected that nurses monitor all medications for adverse effects as part of usual nursing practice. For coding purposes, this monitoring relates to management of pharmacotherapy and not to management or monitoring of the underlying disease. • Item I2300 Urinary tract infection (UTI): — tive disease instead of 7 days. The UTI has a look- back period of 30 days for ac — Code only if both of the following are met in the last 30 days : It was 1. -based criteria d a UTI using evidence determined that the resident ha , such as McGeer , NHSN, or Loeb in the last 30 days AND A physician documented UTI diagnosis (or by a nurse practitioner, physician 2. assistant, or clinical nurse specialist if allowable under state licensure laws) in . the last 30 days I-11 October 2018 Page

387 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] in the Last 7 Days (cont.) I: Active Di agnoses — In accordance with requirements at §483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of ame recognized surveillance criteria. Facilities are expected to use the s nationally recognized criteria chosen for use in their Infection Prevention and Control nationally Program to determine the presence of a UTI in a resident. Example: if a facility chooses to use the Surveillance Definitions of Infections — (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI. — If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence -based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hos pital transfer summary or other paperwork. When the resident is transferred, but not admitted, to a hospital (e.g., emergency room — visit, observation stay) the facility must use evidence -based criteria to evaluate the for UTI are met AND verify that there is a resident and determine if the criteria physician -documented UTI diagnosis when completing I2300 Urinary Tract Infection (UTI). — Resources for evidence- based UTI criteria: • Loeb criteria: https://www.researchgate.net/publication/12098745_Development_of_Minimum_ Criteria_for_the_Initiation_of_Antibiotics_in_Residents_of_Long- Term - Care_Facilities_Results_of_a_Consensus_Conference Surveillance Definitions of Infections in LTC (updated McGeer criteria): • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/ • National Healthcare Safety Network (NHSN): https://www.cdc.gov/nhsn/ltc/uti/index.html egarding the resident with colonized MRSA, we consulted with In response to questions r the Centers for Dise ase Control (CDC) who provided the following information: A physician often prescribes empiric antimicrobial therapy for a suspected infection after a culture is obtained, but prior to receiving the culture results . The confirmed diagnosis of UTI will depend on the culture results and other clinical assessment to determine appropriateness and continuation of antimicrobial therapy. This should not be esident is known to be colonized with an antibiotic resistant any different, even if the r organism . An appropriate culture will help to ensure the diagnosis of infection is correct, and the appropriate antimicrobial is prescribed to treat the infection. The CDC does not -12 October 2018 Page I

388 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) recommend routine antimicrobial treatment for the purposes of attempting to eradicate colonization of MRSA or any other antimicrobial resistant organism. The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) has released infection prevention and control guidelines that contain recommendations that should be applied in all healthcare settings. At this site you will find information related n LTC. to UTIs and many other issues related to infections i http://www.cdc.gov/hai/ • Item I5100 Quadriplegia: Quadriplegia primarily refers to the paralysis of all four limbs, arms and legs, caused — by spinal cord injury. — Coding I5100 Quadriplegia is limited to spinal cord injuries and must be a primary diagnosis and not the result of another condition. Functional quadriplegia refers to complete immobility due to severe physical — disability or frailty. Conditions such as cerebral palsy, stroke, contractures, brain se, advanced dementia, etc. can also cause functional paralysis that may extend disea to all limbs hence, the diagnosis functional quadriplegia. For individuals with these types of severe physical disabilities, where there is minimal ability for purposeful movement, their primary physician-documented diagnosis should be coded on the MDS and not the resulting paralysis or paresis from that condition. For example, an individual with cerebral palsy with spastic quadriplegia should be coded in I4400 Cerebral Palsy, and not in I5100, Quadriplegia. Examples of Active Disease 1. A resident is prescribed hydrochlorothiazide for hypertension. The resident requires regular blood pressure monitoring to determine whether blood pressure goals are achieved by the current regimen . Physician progress note documents hypertension. checked Coding: Hypertension item ( I0700), would be . Rationale: This would be considered an active diagnosis because of the need for ongoing monitoring to ensure treatment efficacy. 2. Warfarin is prescribed for a resident with atrial fibrillation to decrease the risk of embolic stroke. The resident requires monitoring for change in heart rhythm, for bleeding, and for anticoagulation. Coding: Atrial fibrillation item ( I0300), would be checked . This would be considered an active diagnosis because of the need for Rationale: sure treatment efficacy as well as to monitor for side effects ongoing monitoring to en related to the medication. -13 October 2018 Page I

389 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [I] I: Active Diagnoses in the Last 7 Days (cont.) -steroidal anti- y of healed peptic ulcer is prescribed a non 3. A resident with a past histor inflammatory (NSAID) medication for arthritis. The physician also prescribes a proton-pump inhibitor to decrease the risk of peptic ulcer disease (PUD) from NSAID treatment. Arthritis Coding: item (I3700), would be checked . Rationale Arthritis would be considered an active diagnosis because of the need for : medical therapy. Given that the resident has a history of a healed peptic ulcer without current symptoms, the proton-pump inhibitor prescribed is preventive and therefore PUD would not be coded as an active disease. 4. The resident had a stroke 4 months ago and continues to have left-sided weakness, visual problems, and inappropriate behavior. The resident is on aspirin and has physical therapy and occupational therapy three times a week. The physician’s note 25 days ago lists stroke. Coding: Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or checked Stroke item ( I4500), would be . Rationale The physician note within t he last 30 days indicates stroke, and the resident : is receiving medication and therapies to manage continued symptoms from stroke. Examples of Inactive Diagnoses (do not code) 1. The admission history states that the resident had pneumonia 2 months prior to this ission . The resident has recovered completely , with no residual effects and no continued adm treatment during the 7 -day look back period. Coding: I2000 ), would not be checked . item ( Pneumonia Rationale The pneumonia diagnosis would not be considered active because of the : resident’s complete recovery and the discontinuation of any treatment during the look- back period. 2. The problem list includes a diagnosis of coronary a rtery disease (CAD). The resident had an angioplasty 3 years ago, is not symptomatic, and is not taking any medication for CAD. . Coding: CAD item ( I0400), would not be checked and no treatment during the 7-day look- The resident has had no symptoms Rationale : back period; thus, the CAD would be considered inactive. 3. Mr. J fell and fractured his hip 2 years ago. At the time of the injury, the fracture was surgically repaired. Following the surgery, the resident received several weeks of physical therapy in an attempt to restore him to his previous ambulation status, which had been ices at that time, he now independent without any devices. Although he received therapy serv requires assistance to stand from the chair and uses a walker. He also needs help with lower body dressing because of difficulties standing and leaning over. Coding: Hip Fracture item ( I3900), would not be checked . : -care limitations in ambulation Rationale Although the resident has mobility and self day and ADLs due to the hip fracture, he has not received therapy services during the 7- look-back period; thus, Hip Fracture would be considered inactive. -14 October 2018 Page I

390 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] SECTION J: HEALTH CONDITIONS Intent: ction is to docum ent a nu mber of health conditions that The intent of the ite ms in this se life. The ite ms incl ude an assessment of impact the resident’s functional status and quali ty of rview with the resi dent or sta ff if the r pain which uses an inte nable to participate. The esident is u pain ite ent ms assess the presence of pain, pain frequency, effect on function, intensity, managem her ite and control. Ot ms in the section assess dyspnea, tobacco use, prognosis, problem conditions, and falls. -Day Look Back) J0100: Pain Management (5 Item Rationale of Life Heal th-related Quality DEFINITION ociated with • Pain can cause suffering and is ass PAIN MEDICATION vity, social withdrawal, depression, and functional inacti REGIMEN decline. Pharmacological agent(s) • Pain can interfere with par ticipation in rehabilitation. prescribed to relieve or • Effective pain m anag ement interventions can help to prevent the recurrence of es. avoid these adverse outcom pain. Include all medications used for pain management Care for ng Planni by any route and any anag ement for most residents should • Goals for pain m - frequency during the look fort while evel of com be to achieve a consistent l back period. Include oral, maintai ning as much function as possible. transcutaneous, subcutaneous, intramuscular, • Identification of pain management interventions rectal , intravenous injections facilitates r eview of the e ffectiveness of pain or intraspinal delivery. This nage ma ment and revision of the plan if goals are not item does not include met. medications that primarily Residents m ay have more than one source of pain and • target treatment of the uali ent anagem zed m will need a comprehensive, individ underlying condition, such as regi men. chemotherapy or steroids, Most residents with m oderate to severe pain will require • although such treatments e will require osed pain m regularly d edication, and som ma y lead to pain reduction. additional P RN (as -needed) pain medications for breakthrough pain. me resid ittent or mild pain may have orders for PRN dosing only. ents with interm So • Page J-1 October 2018

391 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: DEFINITIONS J0100: Pain Management (cont.) SCHEDULED PAIN acologic) -medication pain (non-pharm • Non MEDICATION REGIMEN rventions for pain can be important adjuncts to pain inte Pain medication order that treat ment regi mens. defines dose and specific • an rt of a care pl Interventions must be included as pa time interval for pain ms to prevent or relieve pain and includes that ai medication administration. monitoring for effectiveness and revision of care plan if For example, “once a day,” “every 12 hours.” et. There must be documentation stated goals are not m that the intervention was rece ived and its effecti veness PRN PAIN was assessed. It does not have to have been successful MEDICATIONS to be counted. Pain medication order that specifies dose and indicates Assessment for Steps that pain medication may be 1. edical record to determ ine if a pain re Review m gimen giv en on an as needed basis, exists. including a time interval, such as “every 4 hours as Review the m edical record a nd interview staff and direct 2. needed for pain” or “every 6 ent mine what, if any, pain m caregivers to deter anagem hours as needed for pain.” -day look- interventions the resident re ceived du ring the 5 back period. Include inform ation from all disciplines. NON -MEDICATION PAIN INTERVENTION for J0100A -C Coding Instructions Scheduled and implemented ventions for pain provided to the resident Determine all inter pharmacological non- during the 5-day look-back period. A nswer these items even if interventions include, but are feedback, not limited to, bio the resident currently denies pain. application of heat/cold, Coding Instructions for J0100A, Been on a massage, physical therapy, nerve block, stretching and Scheduled Pain Medication Regimen strengthening exercises, 0, n o: edical record does not contain if the m • Code chiropractic, electrical documentation that a scheduled pain m edication was stimulation, radiotherapy, received. ultrasound and acupuncture. Herbal or alternative ns if the medical record contai 1, y es: Code • medicine products are not documentation that a scheduled pain m edication was included in this category. received. Instructions for J0100B, Received PRN Pain Medication Coding 0, n o: • entation that a PRN record does not contain docum if the medical Code medication was received or offered. if the medical RN m Code 1, y es: ns docu record contai edicati mentation that a P on was • offered but declined. ved OR was either recei October 2018 Page J-2

392 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0100: Pain Management (cont.) Instructions for J0100C, Received Non-medication Coding Intervention for Pain Code 0, n o: • medical record does not contain documentation that a non- if the medication pain intervention was received. • Code 1, y es: if the medical record contai ns documentation that a non-medication pain intervention was scheduled as part of the care plan and it is documented that the intervention was actually received and assessed for efficacy. Coding Tips • Code only pain m edication regi mens without PRN pain m edications in J0100A. Code receipt of PRN pain medications in J0100B. • For coding J0100B code only residents with PR N pain medicat ion regim ens here. If the resident has a scheduled pain medication J0100A should be coded. Examples 1. The resi dent’s medical record documents that she received the following pain m anage ment in the past 5 days: Hydrocodone/acetaminophen 5/500 1 tab PO every 6 hours. Discontinued on day 1 of • look-back period. • Acetaminophen 500mg PO every 4 hours. Started on day 2 of look-back period. Cold pack to left shoulder applied by PT BID. PT notes that resident reports significant • pain improvem . ent after cold pack applied Coding: J0100A would be coded 1, yes . Rationale: Medical record indicated that res ident received a scheduled pain medication during the 5-day look-back period. J0100B be Coding: coded 0, no. would Rationale: No documentation was found in the m edical record that resident received or was offered and declined any PRN medications during the 5- day look- back period. Coding: coded 1, yes. J0100C would be Rationale: The medical record indicates that the resident received scheduled non- medication pain intervention (cold pack to the left shoulder) during the 5- day look- back period. 2. The resi dent’s m edical record i nclu des the following pain management documentation: • Morphine sulfate controlled- release 15 mg PO Q 12 hours: Resident refused every dose of medication during the 5-day look-back period. No other pain m anag ement interventions were docum ented. October 2018 Page J-3

393 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0100: Pain Management (cont.) ng: J0100A would be coded 0, no . Codi ionale: The m Rat ented that the resident did not receive edical record docum scheduled pain medication during the 5-day look-back period. Residents m ay refuse scheduled m edication s; however, medications are not considered “recei ved” if the resident refuses the dose. . 0, no Codi ng: J0100B would be coded docum Rat The m edical record contained no ionale: entation that the resident received or was offered and declined any PRN medications during the 5- day look- back period. . Codi J0100C would be coded 0, no ng: Rat ionale: The medical record contains no documentation that the resident pain intervention during the 5-day look-back period. medication received non- J0200: Should Pain Assessment Interview Be Conducted? Item Rationale -related Quality Health of Life unicating can answer questions about how they • Most residents who are capable of comm feel. Obtaining information about pain directly from the resident, som • es called “hearing etim the resident bservation alone for identifying ’s voice,” is more reliable and accurate than o pain. If a resident cannot co mm unicate (e.g., verbal, gesture, written), then staff observations • for pain behavior (J0800 and J0850) will be us ed. Planni ng Care for • Inter view allows the re sident’s voice to be reflected in the care plan. • Infor mation about pain that com es directly from t he resident provides symptom- specific information for individualized care planning. Steps for Assessment 1. Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. October 2018 Page J-4

394 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0200: Should Pain Assessment Interview Be Conducted? (cont.) Deter mine whether or not the resident is rarely/never understood verbally, in writing, or 2. using another method. If the resident is rarely/never understood, skip to item J1100, Shortness of Breath. Review Langua ge 3. mine whether or not the resident needs or wants an item (A1100) to deter interpreter. If the reside nt needs or wants an interpreter, complete the interview with an interpreter. • Coding I nstructions st sometimes understood and an Attempt to complete the interview if the resident is at lea sent or not required. inte rpreter is pre Code 0, n o: if the resident is rarely/never unders tood or an interpreter is required but • In not available. Skip to item (J0800). dicators of Pain or Possible Pain • Code 1, y es: if the resident is at least so metimes understood and an interpreter is present or not required. Continue to Pain Presen ce item (J0300). Special Coding Populations Tips and • residents. This interview is conducted during Attempt to conduct the interview with ALL the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. If the resident interview should have been conducted, but was not done with in the look- • (except when an interpreter is needed/requested and back period of the ARD unavailable), item J0200 must be coded 1, Yes, and the standard “no information” code (a dash “- ”) entered in the resident interview items J0300–J0600. Item J0700, Should the Staff Assessment for Pain be Conducted, is coded 0, No. • Do not complete the Staff Assessment for Pain items (J0800–J0850) if the resident interview should have been conducted, but was not done. • If it is not possible for an interpreter to be present during the look-back period, code Staff Assessment of Pain J0200 = 0 to indicate interview not attempted and com plete item ms (J0300-J0600). ite (J0 800), instead of the Pain Int erview There is one exception to completing the Staff Assessment for Pain items (J0800–J0850) • in place of the resident interview. This exception is specific to a stand-alone, unscheduled Prospective Payment System ( PPS ) assessment only and is discussed on page 2-60. For this type of assessment only, the resident interview may be conducted up to two calendar days after the ARD. • When coding a stand-alone Change of Therapy OMRA (COT), a stand-alone End of Therapy OMRA (EOT), or a stand-alone Start of Therapy OMRA (SOT), the interview items may be coded using the responses provided by the resident on a previous if the DATE assessment only of the interview responses from the previous assessment (as of documented in item Z0400) was obtained no more than 14 days prior to the DATE completion for the interview items on the unscheduled assessment (as documented in item Z0400) for which those responses will be used. October 2018 Page J-5

395 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0300-J0600: Pain Assessment Interview Rationale Item Health Quality of Life -related • The effects of unrelieved pain i mpact the individual in terms of functional decline, complications of immobility, skin breakdown and infections. ’s q htly linked to tig • Pain signi fic antly ad versely a ffects a person e and is uality of lif depression, di confidence and s elf-esteem , as well as an increase in minished self- behavior problems, particular ly f or cognitively -impaired r esidents. • So avoid having pain. Their report of me older adults lim it their a cti vities in or der to lower pain fr equency m ay reflect their avoidance of activity more than it reflects nt. adequate pain m anage me October 2018 Page J-6

396 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: (cont.) J0300-J0600: Pain Assessment Interview for Planni Care ng • Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain. Resident self -report is the most reliable m eans for asses sing pain. • Pain assess ment provides a basis for evaluation, treat ment need, and response to • ment. treat hether pain interferes with sleep or ac tivities provides additional • Assessing w understanding of the functional impact of pain and potential care planning im plications. Assessment of pain provides insight into the n eed to adjust the ti ming of pain • interventions to better cover sleep or preferred activities. ment prompts discussion about factors that aggravate and alleviate pain. • Pain assess • sti muli can have var ying i mpact on different individuals. Similar pain ale i Consistent lidity and reliability • mproves the va use of a stan dardi zed pain inten sity sc of pain assessment. Using the sam di fferent s ettin gs m ay i mprove continuity of e scale in care. • Pain intensity scales allow providers to e valuate whether pain is responding to pain medication regi men(s) and/or non-pharm acological intervention(s). Steps for Assessment: Basic Interview Instructions for Pain Assessment Interview (J0300 -J0600) hould Pain Assessment Interview 1. Interview any resident not screened out by the S be item (J0200). Conducted? 2. The Pain Assess ment Interview for resident s c onsists of four items: the primary question up questions nce item (J0300), and three follow- item (J0400); Pain Frequency Pain Prese Pain Effect on Function item (J0500); and Pain Intensity item (J0600). If the resident is unable to answer the primary question on Pain Presence item J0300, skip to the Staff item (J0800). Assessment for Pain beginning with Indicators of Pain or P ossible Pain October 2018 Page J-7

397 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] (cont.) J0300-J0600: Pain Assessment Interview 3. The look-back period on these items is 5 days. Be cause this item asks the resident to recall pain during the past 5 days, this assessment should be conducted close to the end of the 5- efore, or the day of the ARD. This should more day look-back period; preferably on the day b occur during the 5-day look-back period. accurately capture pain episodes that 4. Conduct the interview in a private setting. 5. Be sure the resident can hear you. mmunication ested using their usual co • Residents w ith hearing impair ment should be t devices/techniques, as applicable. • Try an external assistive device (headphones or hearing amplifier) if you have any doubt about hearing ability. • Minimize background noise. he resi 6. Sit so that t dent can see your face. Mi nimi ze glare by directing li ght sources away from the resident’s face. 7. Give an introduction bef ore starting the intervie w. Suggested language: “I’d like to ask you some qu estions about pain. The reason I am asking these questions is to understand how have pain, how severe it is, and how pain affects your daily activities. This will often you help us to develop the best plan of care to help manage your pain.” 8. Directly ask the resident each item gh J0600 in J0300 throu DEFINITION in the order provided. PAIN ms for pain or follow-up discussion if the Use other ter • Any type of physical pain or resident seems unsure or hesitant. Some residents avoid discomfort in any part of the use of the term “pain” but may report that they “hurt.” body. It may be localized to Residents m ay use other ter ms such as “aching” o r one area or may be more “burning” to descri be pain. generalized. It may be acute answer a particular item, If the resident chooses not to 9. or chronic, continuous or intermittent, or occur at rest code 9 , and move on to the next accept his/ her refusal, or with movement. Pain is item. very subjective; pain is If the resident is unsure about whether the pain occurred in 10. whatever the experiencing al, prompt the resident to think about the 5- day ti me interv person says it is and exists the most recent episode of pain and try to determ ine whenever he or she says it ccurred within the look-back period. whether it o does. Back) Day Look J0300: Pain Presence (5- October 2018 Page J-8

398 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0300: Pain Presence (cont.) Assessment for Steps DEFINITION e Ask the resident: “Have you h ad pain or hurting at any tim 1. in the last 5 days?” NONSENSICAL ONSE RESP for Instructions J0300, Pain Presence Coding elated, unr Any Code for the presence or absence of pain regardless of pain or sible, incomprehen -day look-back period. management efforts during the 5 is t hat response incoherent not with respect informative • 0, n o: if the resident responds “no” to any pain Code coded. b eing to the item 0, no: Code the even if in the 5-day look-back period. ment interventions. If coded anage reason for no pain is that the resident received pain m w is co vie 0, the pain inter (J1100). item hortness of Breath S mplete. Skip to • 1, y es: pain at any “yes” to time during the look- back Code if the resident responds period. If coded 1, proceed to items J0400, J0500, J0600 AND J0700. • Code 9, u nable to a nswer: if the resident is unable to answer, does not respond, or gives a nonsensical response. Staff Assessment for Pain If coded 9, skip to the beginning w ith Indicators of Pain or Possible Pain item (J0800). Tips Coding Rates of self -reported pain are higher than observed rates. Although som e observers have • expressed concern that residents may not complain and may deny pain, the regular and to objective use of self -report p ain scales enhances resid ents’ w illingness report. Examples 1. When asked about pain, Mrs. S. responds, “No. I have been taking the pain m edication regularly, so fortunately I have had no pain.” . The assessor would skip to Shortness of 0, no Codi ng: J0300 would be coded item (J1100). Breath Mrs. S. reports having no pain during the look-back period. Even though Rat ionale: anagement interventions during the look-back period, the item is she received pain m coded “No,” because there was no pain. 2. When asked about pain, Mr. T. responds, “No pain, but I have had a terrible burning y leg.” sensation all down m J0300 would be ng: Codi Pain . The assessor would proceed to 1, yes coded Frequency item (J0400). he ionale: indicate that Rat Although Mr. T.’s initial response is “no,” the comments has experienced pain (burning sensation) during the look-back period. Page J-9 October 2018

399 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0300: Pain Presence (cont.) When asked about pain, Ms. G. responds, “I was on a train in 1905.” 3. J0300 would be The assess 9, unable to respo nd . ng: or would skip to Codi coded Indicators of Pain item (J0800). Rat ionale: Ms. G. has provided a nonsensical answer to the question. T he assess or will Staff Ass essment for Pain complete the In dicators of Pain item beginning with (J0800). ( ) J0400: Pain Frequency 5-Day Look Back for Assessment Steps Ask the resident: “How much of the tim e have you experienced pain or hurting over the last 1. 5 days?” Staff may present response options on a written sheet or cue card. This can help the resident respond to the ite ms. 2. If the resident provides a related response but does not use the provided response scale, help the nt and providing me com own clarify the best response by echoing (repeating) resident’s related response options. This interview approach frequently helps the resident clarify which response option he or she prefers. 3. If the resident, despite clarifying state ment and repeating response options, continues to have difficulty selecting between two of the provided responses, then select the m ore frequen t of the two. Coding I nstructions Code for pain frequency during the 5-day look-back period. • Code 1, al most con stantly: if the resident responds “almost constantly” to the question. if the resident responds “frequently” to the question. Code tly: 2, frequen • • sident responds “occas Code 3, o ccasional ly: if the re ionally” to the question. • Code 4, ra rely: if the resident responds “rarely” to the question. to a nswer: if the resident is unable to respond, does not respond, or • Code 9, u nable 0500, J0600 AND J0700. s J gives a nonsensical response. Proceed to item 10 October 2018 Page J-

400 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0400: Pain Frequency (cont.) Coding Tips • No predetermined definitions are offered to the resident related to frequency of pain. — The response should be based on the resident’s interpretation of the fr equency options. — Facility policy should provide standardized tools to use throughout the facility in assessing pain to ensure consistency in interpr etation and documentation of the resident’s pain. Examples e. It has been a terrible week. I have When asked about pain, Mrs. C. responds, “All the tim 1. me since I started physical nutes at a ti not been able to get comfortable for more than 10 mi therapy four days ago.” Coding: coded 1, almost constantly . J0400 would be Rat ionale: Mrs. C. pain that has occurred “ all the tim e.” describes 2. When asked about pain, Mr. J. responds, “I don’t know if it is frequent or occasional. My e from the bed or the wheelchair.” knee starts throbbing every tim e they m ove m y ti me they move you. If you had to choose The interviewer says: “Your knee throbs ever an answer, would you say that you have pain frequently or occasionall y?” Mr. J. is still unable to choose between frequently and occasionally. ng: J0400 would be coded 2, fre quently . Codi ionale: oed Mr. J.’s comment and provided The interviewer appropriately ech Rat related response options to help him clarify which response he preferred. Mr. J. rem ained unable to de cide between frequently and occasionally. The i nter viewer t herefore coded for the higher frequency of pain. about pain, Miss K. responds: “I can’t remember. I think I had a headache a few 3. When asked uple of days, but they gave m e acetaminophen and the headaches went tim es in the past co away.” The inte rvi ewer cl arifies by echoing what Mi ss K. said: “You’ve had a headache a few times in the past couple of days and the headaches went away when you were given acetaminophen. If you had to choose from the answers, would you say you had pain nally occasio or rarel y?” Miss K. re onally.” plies “Occasi Codi ng: . coded 3, occas ion ally J0400 would be After the interviewer c larified the resident’s choice using echoing, the Rat ionale: resident selected a response option. 11 October 2018 Page J-

401 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] (cont.) J0400: Pain Frequency 4. When asked about pain, Ms. M. responds, “I would say rarely. Since I started using the , I don’t have much pain at all, but four days ago the pa in came back. I think they were patch a bit overdue in putting on the new patch, so I had so me pain f at day.” or a little while th Codi J0400 would be coded 4, rarely . ng: Rat the “rarely” response option. Ms. M. ionale: selected J0500: Pain Effect on Function (5-Day Look Back) Steps for Assessment 1. Ask the re sident each of the two questions ex actly as they are written. 2. If the resident’s response does not lead to a clear “yes” or “no” answer, repeat the resident’s response and then try to narrow the focus of the response. For example, if the resident responded to the question, “Has pain made it hard for you to sl ?” by saying, “I eep at night always have trouble sleeping,” then the assessor might reply, “You always have trouble sleeping. Is it your pain that makes it hard for you to sleep? Coding Instructions for J0500A, Over the Past 5 Days, Has Pain Made It Hard for You to Sleep at Night? • Code 0, n o: if the resident responds “no,” indica ting that pain did not interfere with sleep. • Code 1, y es: if the resident responds “yes,” indicating that pain interfered with sle ep. Code 9, u nable to a nswer: if t he resident is unable to answer the question, does not • respond or gives a nonsensical response. Proceed to item s J0 500B, J0600 AND J0700. Coding Instructions for J0500B, Over the Past 5 Days, Have You Limited Your Day -to-day Activities because of Pain? resident indicates that pain d • Code 0, n o: if the id not interfere with daily activities. • if the resident indicates that p Code 1, y es: ain interf ered with d aily a ctivities. Code 9, u nable to a nswer: if the resident is unable to answer the question, does not • 700. respond or gives a nonsensical response. Proceed to item 600 AND J0 s J0 12 October 2018 Page J-

402 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0500: Pain Effect on Function (5-Day Look Back) (cont.) for J0500A, Over the Past 5 Da ys, Has Pain Made It Hard for Examples You to Sleep at Night? be ing in the wheelchair all day, but it felt so 1. Mrs. D. responds, “I had a little back pain from much better when I went to bed. I slept like a baby.” Coding: coded 0, no . J0500A would be Rationale: Mrs. D. reports no sleep problems related to pain. 2. Mr. E. resp onds , “I ca n’t sleep at all in this place.” The interviewer clarifies by saying, “You can’t sleep here. Would you say that was because pain made it hard for you to sleep at night?” Mr. E. responds, “No. It has nothing to do with me. I have no pain. It is because everyone is making so much noise.” ng: J0500A would be coded 0, no Codi . Rat ionale: Mr. E. reports that his sleep problems are not related to pain. 3. Miss G. responds, “Yes, the back pain m akes it h ard to sleep. I have to ask for extra pain medicine, and I still wake up several ti mes during the night because my back hurts so much.” Codi ng: J0500A would be coded 1, yes . Rat ionale: The resident reports pain-related sleep problem s. Examples for J0500B, Over the Past 5 Days, Have You Limited Your Day -to-day Activities because of Pain? esday, but I didn’t want to miss the shopping edn ain on W e p L. responds, “No, I had som 1. Ms. trip, so I went.” J0500B would be coded 0, no . ng: Codi ionale: Rat Ms. L. reports pain, she did not lim it her activity because of it. Although 2. Mrs. N. res ponds, “Yes, I haven’t been able to play the piano, because m y shoulder hurts.” Codi ng: J0500B would be coded 1, yes . pain. Rat ionale: Mrs. N. re ports lim iting her ac tivitie s because of 3. Mrs. S. responds, “I don’t know. I have not tried to knit since my finger swelled up yester , because I am afraid it might hurt even more than it does now.” day Codi ng: J0500B would be coded 1, yes . Rat ionale: Resident avoided a usual activity because of fear that her pain would ease. incr 4. Mr . Q. responds, “I don’t like painful activities.” Interviewer repeats question and Mr. Q. responds, “I designed a plane one tim e.” Codi J0500B would be coded 9, una ble to ans wer . ng: Rat Resident has provided a nonsensical answer to the question. Proceed to ionale: items J0600 AND J0700. 13 October 2018 Page J-

403 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0600: Pain Intensity (5-Day Look Back) Steps for Assessment You m ay u se either Numeric Rati 1. item (J0600A) or Verbal Descriptor Scale item ng Scale (J0600B) to interview the resident about pain intensity. • For each resident, try to use the sam e scale u sed on prior asse ssm ents. 2. If the resident is unable to answer using one scale, the other scale should be attempted. Verbal 3. either the Numeric Rating Scale item (J0600A) or the Record Descriptor Scale item (J0600B). Leave the response for the unused scale blank. 4. Read the question and item choices slowly. While reading, you may show the resident the response options (the Numeric Rati ng Scale or V erbal Descriptor Scale ) clearly printed on a piece of paper, such as a cue card. Use lar ge, clear print. • For the Numeric Rati ng Scale , say, “Please rate your wor st pain over the last 5 days with zero being no pain, and ten as the worst pain you can imagine.” , say, “Please rate the intensity of your worst pain over the e Verbal Descriptor Scal For • last 5 days.” The resident m ay pro vide a verbal response, point to the written response, or both. 5. (00 Instructions for J0600A. Numeric Rating Scale -10) Coding Enter the two digit number (00-10) indicated by the resident as corresp sity of onding to the inten his or her worst pain during the 5-day look-back period, where zero is no pain, and 10 is the worst pain imaginable. Enter 99 if unable to an sw er. • meric Rating Scale is not used, leave the response box blank. • If the Nu Instructions J0600B. Scale Coding Descriptor for Verbal Code 1, m ild: if resident indicates that his or her pain is “ mild.” • ate: • Code 2, moder if resident indicates that his or her pain is “m oderate.” • Code 3, s evere: if resident indicates that his or her pain is “severe.” at his or her pain is “very e: ates th horribl ere, Code 4, v ery sev if resident indic • severe or horrible.” 14 October 2018 Page J-

404 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0600: Pain Intensity (cont.) Code 9, u nable to a nswer: if resident is unable to answer, chooses not to respond, • does not respond or gives a nonsensical response. Proceed to item J0700. Verbal Descript or Scale • is not used, leave the response box blank. If the J0600A. for Scale (00-10) Numeric Examples Rating The nurse asks Ms. T. to rate her pain on a scale of 0 to 10. Ms. T. states that she is not sure, 1. he has shoulder pain and knee pain, and sometim es it is really bad, and som eti mes it because s t all the p is OK. The nurse reminds Ms. T. to think abou ain she had during the last 5 days and mber that des cribes her worst pain. She report select the nu s that her pain is a “6.” ng: coded 06 . Codi J0600A would be ionale: The resident said her pain was 6 on the 0 to 10 scale. Because a 2- Rat digit number is required, it is entered as 06. ews u se of the scale, and provides the 0 to 10 2. The nurse asks Mr. S. to rate his pain, revi visual aid mbers.” The nurse explains that the . Mr. S. says, “My pain doesn’t have any nu numbers help the staff understand how severe his pain is, and repeats that the “0” end is no pain and the “10” end is the worst pain imaginable. Mr. S. replies, “I don’t know where it would fall.” . to answer J0600A would be wer rvie Codi ng: Item The inte coded 99, unable would go on to ask about pain intensity using the item Verbal Descriptor Scale (J0600B). ionale: The resident was unable to select a n umber or point to a location on the 0-10 Rat repres ented h is level of pain intensity. scale that Examples for J0600B. Verbal Descriptor Scale 1. The nurse asks Mr. R. to rate his pain using the verbal descriptor s cale. He looks at the response options presented using a cue card and says his pain is “severe” so metimes, but mild.” most of the tim e it is “ ng: J0600B would be Codi . 3, severe coded Rat The resident said hi s worst pain was “Severe.” ionale: 2. The nurse asks Ms. U. to rate her pain, revi ews use of the verbal descriptor scale, and provides a cue card as a visual aid. Ms. U. says, “I’m not sure whether it’s mild or moderate.” The nurse reminds Ms. U. to think about her worst pain during the last 5 days. Ms. U. says “At its worst, it was m oderate.” Codi ng: Item coded 2, moder ate . J0600B would be The resident indicated that her worst pain was “Moderate.” Rat ionale: 15 October 2018 Page J-

405 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0700: Should the Staff Assessment for Pain be Conducted? (5-Day Look Back) Item Rationale J0700 closes the pain interview and determi nes if the resident inte rview was complete or Item inco ff assess ment needs to be com pleted. mplete and based on this determination, whether a sta Health -related Quality of Life DEFINITION Resident interview for pain is pr eferred because it • ETED COMPL all improves the detection of pain. However, a sm EW INTERVI percentage of residents are unable or unwilling to interview pain is The view. complete the pain inter successfully com pleted if the rview may still Persons una ble to co mplete t he pain inte • no pain resident reported have pain. No (answered or if to J0300), the resident reported pain Planni Care for ng (J0300=yes) and follow - the question J0400 is up • Resident self ost reliable means of -report is the m answered. assessing pain. However, when a resident is unable to ation, staff assess ment is necessary. provide the inform y • Even though the resident was unable to complete the interview, important insights ma be gained from the responses that were ob tained, observing behaviors and observing the resident’s affect during the interview. Steps for Assessment Review the resident’s responses to items J0200-J0400. 1. Pain Assessme 2. The Staff A ssessment for Pain should only be com pleted if the nt Interview (J0200-J0600) was not completed. the Instructions for J0700. Should Coding Staff Assessment for Pain be completion Conducted? This item is to be coded at the of J0400 items -J0600. item (J0400 = 0, n o: Code • Pain Assessme mpleted the if the resident co nt Inter view 1, 2, 3, or 4. Skip to Shortness of Breath (dyspnea) item (J1100). 1, y es: Code view ain Assessment Inter P esident was unable to complete the if the r • item (J0800). Indicators of Pain or P ossible Pain (J0400 = 9). Continue to 16 Page J- October 2018

406 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J0800: Indicators of Pain (5-Day Look Back) Complete t Assessment Interview (J0200-J0600) was not completed. his item only if the Pain Rationale Item Quality of Life Health -related Residents who cannot verbally communicate about their pain are at particularly high risk • for underdetection and undertreatment of pain. Severe cog nitive i • ment m ay af fect the ability of residents to v erbally communicate, mpair thus lim the availabi lity of self -reported information about pain. In this population, iting mpl ay not m fewer co ean less pain. aints m • Individuals who are unable to verbally communi cate may be more likely to use alternative methods of expression to communicate their pain. of pain m mplaints e verbal co Even in this population som • ay be made and should be taken seriously. Planni ng for Care oves the accuracy of pain asses • Consistent approach to observation impr sm ent for residents who are unable to verbally communicate their pain. • Particular attention should be paid to using the indicators of pain during activities when pain is most likely to be demonstrated (e.g., bathing, transferring, dressing, walking and potentially during eating). ust carefully monitor, track, and document any possible signs and symptom Staff m s of • pain. Identification of these pain indicators can: • ment, — provide a basis for m ore co mprehensive pain assess — provide a basis for determining appropriate treatment, and — provide a basis for ongoing monitoring of pa in presence and treat ment response. should identify aggravat ment If pain indicators are present, assess ing/alleviating factors • rel ated to pain. 17 October 2018 Page J-

407 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0800: Indicators of Pain (cont.) Assessment Steps for DEFINITIONS medi reco rd for documentation of cal the Review 1. dicator of pain listed in J0800 that occurred during each in NON VERBAL SOUNDS -day look-back period. If the 5 the record docu ments the e.g., crying, whining, s listed, confirm presence of any of the signs and symptom gasping, moaning, groaning irect care staff on all shifts your record review with the d or other audible indications associated with pain. during activities of the resident who work most closely with daily living (ADL). VOCAL COMPLAINTS 2. ay fail to because the m staff erview Int edical record m OF PAIN or any in note all observable pain behaviors. F dic ators that e.g., “That hurts,” “ouch,” were record review, not noted as present in edical m “stop,” etc. interview direct care staff on a ll shifts who work with the FACIAL EXPRESSIONS resident during ADL. Ask directly about the presence of THAT MAY BE each in dicator that was not noted as being present in the INDICATORS OF PAIN record. e.g., grimaces, winces, 3. Obs erve resident during care activities. If you observe wrinkled forehead, furrowed back during the 5-day look- additional indicators of pain brow, clenched teeth or jaw, period, code the corresponding items. etc. ve ns for pain indicat • Observatio ore sensiti ay be m ors m PROTECTIVE BODY if the resident is observed during ADL, or wound care. MOVEMENTS OR POSTURES Coding I nstructions e.g., bracing, guarding, hat apply in the past 5 days based on staff Check all t rubbing or massaging a body observation of pain indicators. part/area, clutching or holding a body part during rview with the inte ew and If the medical record revi • movement, etc. direct care providers and observation on all shifts signs observed or provide no evidence of pain indicators, Check J0800Z, None of these documented , and proceed to Shortness of Breath item (J1100). • Check J0 800A, non verbal sounds: included but not lim ited to if crying, whining, gasping, moaning, or groaning were observed or reported during the look-back period. included but not lim if the • Check J0 800B, vocal compl aints of pai n: ited to ake vocal co mplaints of pain (e.g. “that hurts,” “ouch,” or resident was observed to m “stop”). 800C, included but not lim Check J0 maces, faci al exp ited to if gri ressions: • winces, wrinkled forehead, furrowed brow, clenched teeth or jaw were observed or reported during the look-back period. stures: included but not dy movements ve bo protecti 800D, Check J0 or po • lim ited to ing a body part/area, or clutching or assag if bracing, guarding, rubbing or m holding a body part during moveme back nt were observed or reported during the look- period. 18 Page J- October 2018

408 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0800: Indicators of Pain (cont.) Check J0 800Z, none of these signs obs erved or d ocum ented: if none of • these signs were observed or reported during the look-back period. Coding Tips ejection of care and decreased activity participation • Behavior change, depressed mood, r hese behaviors and may be related to pain. T ms are identi fied in other sections and sympto not reported here as pain screening items. However, the contribution of pain should be considered when following up on those symptoms and behaviors. Examples 1. edical Mr. P. has advanced dementia and is unable to verbally communicate. A note in his m ments that he has been awake du record docu ring the last night crying and rubbing his elbow. When you go to his room to interview the certified nurse aide (CNA) caring for him , you eports that he has been moaning observe Mr. P. grimacing and clenching his teeth. The CNA r and said “ouch” when she tried to move his arm. Codi ng: Nonverbal Sounds item (J0800A); Vocal Compla ints of Pain item (J0800B); Facial Expressions item (J0800C); and Protective Body Movements or Postures item . checked (J0800D), would be Rat ionale: Mr. P. has demonstrated vocal com plai nts of pain (ouch), nonverbal sounds (crying and moaning), facial expression of pain (grim acing and clenched teet h), and protective body movements (rubbing his elbow). ge Parkinson’s disease and is unable to verbally communicate. There is no -sta Mrs. M. has end 2. docum entation edical record during the 5-day look-back period. T he CNAs of pain in her m e morn caring for her report that on som s and legs are ings she moans and winces when her arm moved during morning care. During direct observation, you note that Mrs. M. cries and atte mpts to pull her hand away when the CNA tries to open the contracted hand to wash it. Codi ng: Nonverbal Sounds ite ms (J0800A); Facial Expressions item (J0800C); and Protective Body Movements or Postures item (J0800D), would be checked . Rat ionale: Mrs. M. has demonstrated nonverbal sounds (crying, m oaning); facial mpt to withdraw). expression of pain (wince), and protective body movem ents (atte ar assive cerebrovascul 3. Mrs. E. has been unable to verbally communicate following a m accident ( ure ulcer. There is no CVA) several months ago and has a Stage 3 press docum entation of pain in her m edical record. The CNA who cares for her reports that she does not seem to have any pain. You observe the resident during her pressure ulcer dressing oaning, facial gri change. During the treat ment, you observe gr maces, and a wrinkled forehead. Facial Expressions ng: Nonverbal Sounds item (J0800A), and Codi item (J0800C), would be check ed . The resident has demonstrated nonverbal sounds (groaning) and facial ionale: Rat acing). expression of pain (wrinkled forehead and grim 19 October 2018 Page J-

409 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J0800: Indicators of Pain (cont.) (cont.) Examples Mr. S. is in a persistent veget ative st ate followi ng a trau 4. matic brain injury. He is unable to verbally communicate. There is no documentation of pain in his m edical record during the 5-day look-back period. The CNA reports that he appears comfortable whenever she cares for hi m. You observe the CNA providing morning care and transferring him from bed to chair. No pain indicators are observed at any time. Codi ng: None of These Signs Ob served or Documented item (J0800Z), would be check ed . Rat ionale: ent have been followed and no pain indicators have All steps for the assessm been documented, reported or directly observed. J0850: Frequency of Indicator of Pain or Possible Pain (5-Day Look Back) Item Rationale Health -related Quality of Life Unrelie uting to dependence, skin ffects function and mobility contrib rsely a ved pain adve • s, and weight loss. breakdown, contracture ’s q Pain signi fic antly ad ver sely a ffects a person lif uality of • e and is tig htly linked to depression, diminished self- confidence and s elf-esteem , as well as to an increase in esidents. behavior problems, particular ly f or c ognitively impaired r for Care Planni ng Assessment of pain frequency provides: • — A basis for evaluating treat ment need and response to treatm ent. — fying optimum tim Information to aide in identi ing of treat ment. Steps for Assessment mine the num direct caregivers to deter ber of 1. Review m edical record and interview staff and days the resident either co mplained of pain or showed evidence of pain as described in J0800 over the past 5 days. 20 October 2018 Page J-

410 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] (cont.) J0850: Frequency of Indicator of Pain or Possible Pain Coding I nstructions Code for pain frequency over the last 5 days. Code 1: if based on staff observation, the resident co • mplained or showed evidence of pain 1 to 2 days. • Code 2: if based on staff observatio n, the resident co mplained or showed evidence of pain on 3 to 4 of the last 5 days. • Code 3: if based on staff observatio n, the resident co mplai ned or showed evidence of pain on a daily basis. Examples Mr. M. is an 80-year old m ale with advanced dementia. During the 5-day look- 1. back period, Mr. M. was noted to be grim acing and verbali zing “ouch” over the past 2 days when his right shoulder was moved. Codi ng: Item J0850 would be coded 1, indi cat ors of pain o bserved 1 to 2 day s . Rat mplaints of pain (“ouch”), facial expression of He has demonstrated vocal co ionale: pain (grimacing) on 2 of the last 5 days. Mrs. C. is a 78-year old fem ale with a h istory of CVA with expressive aphasia and 2. dementia. During the 5-day look-back period, the resident was noted on a daily basis to be rubbing her right knee and grim acing. Codi ng: Item J0850 would be coded 3, indi cat ors of pain o bserved d ail y . Rat ionale: The resident was obser ved with a facial expression of pain (grimacing) and protective body movements (rubbing her knee) every day during the look-back period. J1100: Shortness of Breath (dyspnea) Rationale Item Health -related Quality of Life mptom to residents and lead to • Shortness of breath can be an extrem ely dis tressing sy decreased i and quality of life. nteraction • So meti mes ents co mpensate for shortness of breath by lim iting acti vity. T hey so me resid elevating the head of the bed and ng flat by compensate for shortness of breath when lyi do not alert caregivers to the problem. 21 October 2018 Page J-

411 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J1100: Shortness of Breath (dyspnea) (cont.) ng for Care Planni • Shortness of breath can be an indication of a change in condition requiring further assessment and should be explored. • The care plan should address underlyi ng illnesses that m ay exacerbate s ymptom s of shortness of breath as well as symptom atic treatment for shortness of breath when it is not quickly reversible. Steps for Assessment Interview the resident about shortness of breath. Many residents, including those with m ild to entia, may be able to provide feedback about their own symptom s. moderate dem If the resident is not exp eriencing shortness of breath or trouble breathing during the 1. interview, ask the resident i f shortness of breath occurs when he or she engages in certain acti vities. 2. Review the m edical record for staff docu mentation of the presence of shortness of breath or trouble breathing. Interview staff on all shifts, and fam ily/significant other regarding resident history of shortness of breath, allergies or other environm ental t riggers of shortness of breath. 3. Observe the resident for shortness of breath or trouble breathing. Signs of shortness of breath incl ude: increas ed respirat ory rate, p ursed lip breathing, a prolonged expiratory phase, ern (o nly able to say a audible respirations and gasping for air at rest, inte rru pted spee ch patt uscles to few words before taking a breath) and use of shoulder and other accessory m athe. bre 4. If shortness of breath or trouble breathing is observed, note whether it occurs with certain ns or acti vities. positio nstructions Coding I Check all t hat apply during the 7-day look-back period. Any evidence of the presence of a symptom of shortness of breath should be captured in this item. A resident may have any combination of these symptoms. ent w Check J1 100A: if shortness of breath or trouble breathing is pres • hen the resi dent is engaging in activity. Shortness of breath could be present during a ctivity as lim ited as turning or moving in bed during daily care or with more strenuous activity such as transferring, walking, or bathing. If the resident avoids activity or is unable to engage in esent. activity because of shortness of breath, then code this as pr ent w Check J1 100B: if shortness of breath or trouble breathing is pres hen the resi dent • is sitting at rest. 100C: • Check J1 if shortness of breath or trouble breathing is pres ent w hen the resi dent atte flat because of mpts to lie flat. Also code this as present if the resident avoids lying shortness of breath. • Check J1 100Z: if the resident reports no shortness of breath or trouble breathing and aff interviews indic ate that shortness of breath appears to be the m edical record and st absent or well controlled with current medication. 22 October 2018 Page J-

412 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1100: Shortness of Breath (dyspnea) (cont.) Examples 1. Mrs. W. has diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. She is on 2 liters of oxygen and daily respirat ory treat ments. With oxygen she is able to ambulate and participate in most group activities. She reports feeling “winded” when going on outings that require walking one or more blocks and has been observed having to stop mes under such circum stances. Rece ntly, she describes feeling “out of to rest several ti wn. breath” when she tries to lie do ng: J1100A and J1100C would be checked . Codi W. reported being short of breath when lying down as well as during Mrs. Rat ionale: ating lo nger di st ances. outings that required ambul 2. Mr. T. has used an inhaler for years. He is not typically noted to be short of breath. T hree ild trouble with days ago, during a respiratory illness, he had m his breathing, even when to limit group activities. sitting in bed. His shortness of breath also caused him J1100A and J1100B would be Codi ng: checked . Mr. T. was short of breath at rest and was noted to avoid activities because Rat ionale: of shortness of breath. J1300: Current Tobacco Use Rationale Item Health -related of Life Quality • The negative effects of smoking can shorten life expectancy and crea te health problem s that interfer e with daily activities and adversely affect quality of life. Planni ng for Care • This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. • modation of an t ental accom If cessation is declined, a care pl environm hat allows safe and resident preferences is needed. Steps for Assessment DEFINITION rm 1. Ask the re sident if he or she used tobacco in any fo during the 7-day look-back period. TOBACCO USE If the re si dent states that he or she u sed tobacco in som e 2. Includes tobacco used in any code 1, yes . form during the 7-day look-back period, form. 23 October 2018 Page J-

413 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1300: Current Tobacco Use (cont.) If the resident 3. e to ans wer or indicates t hat he or s he did not use tobacco of any kind is unabl during the look- back period, review the m edical record and interview staff for any indication of tobacco use by the res ident during the look-back period. Coding I nstructions • Code 0, n o: if there are no indications that the reside nt used any fo rm of tobacco. ce ind Code 1, y es: if the resident or a ny other sour icates that the r esident used tobacco • in som e fo rm during the look-back period. J1400: Prognosis Item Rationale DEFINITION -related Health Quality of Life CO NDITION OR that m ay result Residents with conditio ases • ns or dise CHRONIC DISEASE han 6 months have special in a life expectancy of less t IN THAT MAY RESULT pallia it from needs and may benef e tive or hospic A LIFE EXPECTANCY services in the nursing hom e. THAN LESS OF 6 Care Planni ng for NTHS MO If life expectancy is less than 6 months, • In t he physician’s nt, judgme interdisciplinary team care planning should be based resident has the a diagnosis on the resident’s preferences for goals and or combination o f clin ical interventions of care whene ver possible. at ha conditio ve ns th ue t o advanc ed (or will contin for Steps Assessment point th at th e dete rior ate) to a ent sid average re h th wit at Review the m mentation by the edical record for docu 1. be not would of illness level physician that the resident’s condition or chronic disease re cted expe rvi ve mo to su may result in a life expectancy of less than 6 mo nths, or th an 6 months. inal illness. that they h ave a t erm should b e This judgment 2. If the physician states that the resident’s life expectancy ysici an anti ated by a ph subst ent may be less than 6 months, request that he or she docum note. It can be difficult to dical record. Do not code until there is this in the me fe pinpoint the exact li the m entation in docum edical record. a single for ex pectancy mine whether the 3. Review the m edical record to deter nt me resident. Physician judg resident is receiving hospice services. shou on typ based ld be or ical f av erage life expectancy o level similar with residents of s dise ase bur den as thi resident. 24 Page J- October 2018

414 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J1400: Prognosis (cont.) DEFINITIONS Coding I nstructions HOSPICE SERVICES if the m edical record does not contain A program for terminally ill • Code 0, n o: persons where an array of minally physician docu mentation that the resident is ter services is provided for the ill and the r esident is not rece iving h ospice s ervi ces. palliation and management • if the medical record includes physician Code 1, y es: of terminal illness and related conditions. The hospice must minally ill; or docum entation: 1) that the resident is ter be licensed by the state as a esident is receiving hospice services. 2) the r hospice provider and/or Examples certified under the Medicare program as a hospice 1. Mrs. T. has a diagnosis of heart failure. During the past few provider. Under the hospice months, she has had three hospital admissions for acute program benefit regulations, a physician is required to me significantly weaker heart f ailure. Her heart has beco document in the medical despite m axi mum treat ment with medications and oxygen. record a life expectancy of Her physician has discussed her deteriorating condition less than 6 months, so if a with her and her family and has documented that her resident is on hospice the prognosis for survival beyond the next couple of months is expectation is that the poor. documentation is in the medical record. Codi . coded J1400 would be ng: 1, yes ionale: The physician docum ented that her life Rat TERMINALLY ILL “Terminally ill” means that expectancy is likely to be less than 6 months. the individual has a medical all cell lung cancer that is 2. Mr. J. was diagnosed with non-sm prognosis that his or her life to his bone. He is not a candidate for surgical or metastatic expectancy is 6 months or J. has been his consent, Mr. ith ment. W curative treat less if the illness runs its ented that referred to hospice by his physician, who docum normal co urse. his life expectancy was less than 6 months. . Coding: J1400 would be coded 1, yes ented that his life ionale: Rat The physician referred the resident to hospice and docum expectancy is likely to be less than 6 months. J1550: Problem Conditions 25 Page J- October 2018

415 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1550: Problem Conditions (cont.) This item provides an opportunity for sc reening in the areas of fever, vo miting, fluid Intent: deficits, and internal bleeding. Clinical screenings provide indications for further evaluation, cal care planning. diagnosis and clini Rationale Item -related Quality of Life Health • Timely assess ment is needed to identify underlying causes and risk for complications. Planni ng for Care • entation of care plans to treat underlying causes and avoid complications is Implem al. critic for Assessment Steps 1. Review the medical record, interview staff on all shifts and observe the resident for any indication that the resident h ad vom iting, fever, potential sig ns of dehydration, or internal bleeding during the 7-da y look-back period. Coding I nstructions box) all that ap ply (blue Check J1550A • , fever • , vom iting J1550B J1550C , dehydrated • • J1550D , i nternal bleeding • J1550Z , none of the above Coding Tips Fever is defined as a temperature 2.4 degrees F higher than baseline. The • Fever: ent Reference tablished the Assessm resident’s baseline temperature should be es prior to Date. g base l • Fever assessment prior to e stablishin ine temper ature: A temperature of 100.4 degrees F (38 degrees C) on admission (i.e., prior to the establish ment of the bas eline te mperature) would be considered a fever. ay be caused by m m any factors (e.g., Regurgitation of sto Vom iting: mach contents; • drug toxicity, infection, psychogenic). 26 October 2018 Page J-

416 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1550: Problem Conditions (cont.) Dehy drated: Check this item if the resi dent presents with two or more of the following • potential indicato rs for dehydration: 1. Resident ta kes in less t han the re com mended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recomm ended intake lev el has been changed from 2,500 m l to 1,500 m l to reflect curre nt practice standards. 2. ore potential clinical signs (indicato rs) of dehydration, Resident has one or m including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnorm al laboratory values (e.g., elevated hemoglobin and hem atocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity). 3. Resident’s fluid loss exceeds the amount of fluids he or she takes in (e.g., loss from ceeds fluid re er, diarrhea that ex ment). place vom iting, fev • Int ernal Bleeding: Bleeding may be frank (such as bright red blood) or occult (such ositive sto as guai ac p ols ). Clinic al indicat ors i nclude black, t arry sto ols, vom iting “co ff ee grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires pack ing. However, nose bleeds that are easily controlled, menses, or a urinalysis that shows a sm all amount of red blood cells should not be coded as internal bleeding. J1700: Fall History on Admission/Entry or Reentry Rationale Item Health -related Quality of Life re a l • Falls a eading cau se of injury, morbidity, and m ortality in older adults. • A previous fall, especially a recent fall, rec urrent falls, and falls with si gnificant i njury are the most important predictors of risk for future falls and injurious falls. mit activities because of a fear of falling and y li • Persons with a history of falling ma should be evaluated for reversible causes of falling. 27 October 2018 Page J-

417 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J1700: Fall History on Admission (cont.) DEFINITION for Planni Care ng FALL mine the potential need for further ass Deter • essment and chan in ge Unintentional intervention, including evaluation of the resident’s need position coming to re st on the ground, f loor or onto t he next for rehabilitation or assistive devices. lower surface (e .g., onto a Evaluate the physical environ • ment as well as staffing or chair, bed, mat). de bedsi r falls. needs for residents who are at risk fo The fall may be witnessed, or an reported b y the resident Steps for Assessment observer or identified when a fo und on the floor resident is The period of review is 180 days (6 months) prior to admission, or ground. Falls include any looking back from the resident’s entry date (A1600). matter it whether fall, no Ask the resident and family or significant other about a 1. occurr ed at home, while out history of falls in the month prior to admission and in the 6 unity, comm an acute in the in months prior to admission. This would include any fall, no or a nursing home. ho spital matter where it occurred. Falls a result of an a re not ex ternal force overwhelming Review int er-f 2. acility tr ansfer in formation (if the resident is (e.g ., a resident pushes y) f or evidence of falls. acilit mitted from another f being ad another resident). acilities ords received fr om f edical rec Review all relevant m 3. he resident resided during the previous 6 months; where t ted intercep An fall occurs also review any other m edical records received for evidence would when the resident have fallen if he or she had of one or m ore falls. o r had cau not /herself ght him the Did J1700A, for Instructions Coding been not intercepted by ll is sti his her person – t anot Time Any a Fall Resident in the Have considered a fall. Last Month to Admission/Entry or Prior CMS understands that Reentr y? challenging a resident’s • Code if resident and family report no falls and 0, n o: balance and training him/her transfer records and medical records do not docum ent a to recover from a loss of balance is an intentional fall in the month preceding the resident’s entry date therapeutic intervention and item (A1600). does not consider anticipated report or t ra nsfer 1, y es: mily if resident or fa Code • losses of balance that occur edical records docu ment a fall in the month recor ds or m during supervised therapeutic interventions as (A1600). preceding t he resident’s entry date item intercepted falls. if the resident is 9, u nable to d etermine: Code • unable to provide the information or if the resident and fam able o r do not ily are not avail edical record in have the information and m deter mine whether formation is inadequate to a fall occurred. 28 Page J- October 2018

418 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1700: Fall History on Admission (cont.) Coding Instructions for J1700B, D id the Resident Have a Fall Any -6 Months prior to Admission/Entry or Time in the Last 2 Reentry? • Code 0, n o: if resident and family report no falls and transfer records and m edical records do not docum ent a fall in the 2 -6 months prior to the r esident ’s e ntry date item (A1600). edical records • Code 1, y es: if resident or fa mily report or transfer recor ds or m (A1600). the resident’s entry date item ent a fall in the 2 docum -6 months prior to • Code 9, u nable to d etermine: if the resident is unable to provide the information, or if the resident and fam ily are not available or do not have the information, and me dical record in form ation is inadequate to deter mine whether a fall occurred. Coding Instructions for J1700C. Did the Resident Have Any Fracture Related to a DEFINITION Fall in the 6 Months prior to FRAC TURE RELATED Admission/Entry or Reentry? TO A FALL b one documented Any ily report no fractures if resident and fam 0, n o: Code • list (in a problem fracture alls and trans fer records and m edical records rel ated to f - an x from a medical rec ord, do not docum ent a fracture related to fall in the 6 ray the re port, or by hist ory of ’s entry date months (0-180 days) preceding the resident resident or caregiver) that item (A1600). occurred of result direct as a recogn or was a fall ized a nd if resident or fa 1, y es: Code mily report or transfer • Do to the later attribut fall. ed records or medical records docum elated ent a fracture r not include caused fractures to fall in the 6 months (0-180 days) preceding the ed by trauma relat to car resident’s entry date item (A1600). cras us estrian vers hes or ped accidents o r impact car of 9, u nable to d etermine: if the resident is • Code ther object person or ano unable to provide the information, or if the resident and ent. the resid against family are not available or do not have the information, mine whether a fall occurred. and medical record information is inadequa te to deter Examples On ad mission interview, Mrs. J. is asked about falls and says she has "not really fallen." 1. However, she goes on to say that when she went shopping with her daughter about 2 w eeks ago, her walker got tangled with the shopping cart and she slipped down to the floor. J1700A would be coded 1, yes Coding: . eet the definition of falls. Falls caused by slipping m Rat ionale: October 2018 Page J- 29

419 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1700: Fall History on Admission (cont.) On ad mi ssion ent denies a history of falling. However, her daughter says 2. interview a resid -4 months ago. that she found her mother on the floor near her toilet twice about 3 ng: J1700B would be coded 1, yes Codi . Rat If the individual is found on the floor, a fall is assu med to have occurred. ionale: On ad mission interview, Mr. M. and his fam ily deny any hi story of falling. However, nursing 3. ried l record docu notes in the transferring hospita to get out of ment that Mr. M. repeatedly t bed unassisted at night to go to the bathroom and was found on a mat placed at his bedside to y the week prior to nursing hom e transfer. prevent injur Codi ng: J1700A would be coded 1, yes . Rat ionale: ocu Medical records from an outside facility d ment that Mr. M. was found on a mat on the floor. This is defined as a fall. Medical records note that Miss K. had hip surgery 5 months prior to admission to the nursing 4. home. Miss K.’s daughter says the surgery was needed to fix a broken hip due to a fall. . ng: Both J1700B and J1700C would be coded 1, y es Codi Miss K. had a fall related fracture 1 e entry. Rat ionale: -6 months prior to nursing hom 5. Mr. O.’s hospital transfer record includes a history of osteoporosis and vertebral compression fractures. The record does not m and Mr. O. denies any history of falling. ention falls, ng: J1700C would be coded 0, no . Codi ionale: Rat fractures were not related to a fall. The 6. Ms. P. has a history of a “Colles’ fracture” of her left wrist about 3 weeks before nursing hom e ad mi ssion. Her son recalls t hat the fracture occurred when Ms. P. tripped on a rug and fell forward on her outstretched hands. . Codi ng: Both J1700A and J1700C would be coded 1, y es ated all -rel fr acture less than 1 month prior to entry. Rat ionale: Ms. P. had a f J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent Item Rationale DEFINITION of Life Health -related Quality PRIOR ASSESSMENT Most recent MDS Falls a re a l eading cau se of • ortality morbidity and m assessment that reported on e residents. among nursing hom falls. Falls result in serious inju ry, especially hip fractures. • Fear of falling can limit an individual’s activity and negatively impact quality of life. • 30 October 2018 Page J-

420 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) for Care Planni ng Identification of residents who are at high risk of falling is a top priority f or care • planning. A previous fall is the most important predictor of risk for future falls. Falls may be an indicator of functional decline and development of other serious • conditions such as delirium, adverse drug reactions, dehydration, and infections. • External risk factors in clude m edication side effects, use of applianc es and restraints, and environmental conditions. A fall should stimulate evaluation of the resident’s need for rehabilitation, ambulation • aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence). Steps for Assessment 1. If this is the first assessme nt/entry or reentry (A0310E = 1), review the m edical record for the time period from the ad mission date to the ARD. 2. If this is n ot the f irst ass essm ent /entry or reentry (A0310E = 0), the review period is from the day after the ent to the ARD of the current assess ment. ARD of the last MDS assessm 3. er it Review all available so urces for any fall sin ce the last assessment, no m atter wheth e. Include nity, in an acute hospital, or in the nursing hom commu ut in the red while o occur medical records generated in any health ment. care setting since last assess Review nursing home incident reports, fall logs and the m nursing, (physician, 4. edical record therapy, and nursing assistant notes). 5. Ask the resident and family about falls during the look-back period. Resident and fam ily reports of falls should be captured here whether or not these incidents are documented in the medical record. Coding I nstructions • Code 0, no: if the resident has not had any fall since the las t asse ssment. Skip to wi ng Disorder item (K0100). Sw allo ment. Continue to Number he last assess Code 1, y es: if the resident has fallen since t • nce Admission/Entry or Reentry or Prior Assessment (OBRA or of Falls Si Scheduled PPS) item (J1900), whichever is m ore recent. Example 1. An incident report describes an event in which Mr. S. was walking down the hall and appeared to slip on a wet spot on the floor. He lost his balance and bumped into the wall, but was able to grab onto the hand rail and steady him self. Coding: J1800 would be coded 1, yes . onsidered a f all. Rat ionale: An intercepted f all is c 31 October 2018 Page J-

421 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] Prior ssion/Entry or Reentry or J1900: Number of Falls Since Admi Assessment (OBRA or Scheduled PPS), whichever is more recent Rationale Item DEFINITION Quality of Life -related Health INJURY RELATED TO A FALL Falls a re a l eading cau se of morbidity and m ortality • Any documented injury that e residents. among nursing hom occurred as a result of, or ry, especially hip fractures. • Falls resu lt in serious inju was recognized within a recurrent falls and falls with Previous falls, especially • short period of time (e.g., injury, are the most im porta nt pre dictor of future f alls hours to a few days) after the us f and injurio alls. fall and attributed to the fall. Care ng for Planni Identification of residents who are at high risk of falling • DEFINITIONS is a top priority for care planning. INJURY (EXCEPT cline and other serious Falls indicate functional de • MAJOR) conditions such as deliriu m, adverse drug reactions, Includes skin tears, dehydration, and infections. abrasions, lacerations, • edication side effects, External ris k factors include m superficial bruises, use of appliances and restraints, and environm ental hematomas, and sprains; or conditions. any fall -related injury that causes the resident to A fall should stimulate evaluation of the resident’s need • complain of pain. for rehabilitation or a mbulation aids and of the need for monitoring or modification of the physical MAJOR INJURY environm ent. Includes bone fractures, joint dislocations, closed head • It is important to ensure the accuracy of the level of injuries with altered injury resulting from a fall. Since injuries can present al consciousness, subdur themselves later than the time of the fall, the assessor hematoma. may need to look beyond the ARD to obtain the accurate informati on for the complete picture of the fall that occurs in the look back of the MDS . October 2018 Page J- 32

422 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Assessment Steps for 1. If this is the first assessment (A0310E = 1), review the m edical record for the ti me period the ad mission date to the ARD. from ter t 2. is n ot the firs t ass essment (A0310E = 0), th e review period is from the day af If this he ARD of the la st MDS assessment to the ARD of the current as sessm ent. er it 3. Review all available so urces for any fall sin ce the last assessment, no m atter wheth occur e. Include ut in the community, in an acute hospital, or in the nursing hom red while o medical records generated in any health care setting since last assess ment. All relevant ceived f rom acute and post- acute f acilities where the resi dent w as ad mitted during records re ore falls. the look-back period should be reviewed for evidence of one or m 4. Review nursing hom e incident reports an d m edical record (physician, nursing, therapy, and nursing assistant notes) for falls and level of injury. 5. Ask the resident, staff, and family about falls during the look-back period. Resident and fam ily reports of falls should be captured here, whether or not these incidents are documented in the m edical record. -up medical information received pertaining to the fall, even if this 6. Review any follow can results), -ray, MRI, CT s emergency room x information is received after the ARD (e.g., and ensure that this information is used to code the assessment. Coding for J1900 Instructions Determine the number of falls that occurred since admission/entry or reentry or prior assessment (O BRA or S cheduled PPS) and code the level of fall-related injury for each. Code each fall only once. If th e resi dent h as m ultiple in juries in a single fall, code the f all for the highest level of injury. Coding Instructions for J1900A, No Injury • Code 0, n one: if the resident had no injurious fall since the adm ission/entry or reentry or prior assessment (OBRA or Scheduled PPS). 1, o ne: mission/entry or reentry if the resident had one non- • Code injurious fall since ad or prior assess ment (OBRA or Scheduled PPS). • Code 2, two or more: if the resident had tw o or more non- injurious falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Instructions Coding for J1900B, Injury (Except Major) all (ex • Code 0, n one: if the resident had no injurious f cept m ajor) since ad mission/entry or reentry or prior assess ment (OBRA or Scheduled PPS). ajor) since ad ntry mission/e • Code 1, o ne: if the resident had one injurious fa ll (ex cept m ment (OBRA or Scheduled PPS). or reentry or prior assess 33 October 2018 Page J-

423 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Code 2, two or more: if the resident had tw o or more injurious fa lls (exce pt m ajor) • mission/entry or reentry or pr since ad ent (OBRA o r Scheduled PPS). ior assessm Coding for J1900C, Major Injury Instructions mission/entry or ous fall since ad • Code 0, n one: if the resident had no major injuri reentry or prior assess ment (OBRA or Scheduled PPS). • 1, o ne: if the resident had one m ajor injurious fall since ad mission/entry or Code ment (OBRA or Scheduled PPS). reentry or prior assess Code 2, two • or more: if the resident had tw o or more major inju rious f alls si nce admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). Coding Tip If the level of injury directly related to a fall that occurred during the look-back period is • after the ARD and is at a different injury level than what was originally coded identified on an assessment that was submitted to QIES ASAP, the assessment must be modified to he level of injury that occurred with that fall. update t Examples 1. A nursing note states that Mrs. K. slipped out of her wheelchair onto the floor while at the table. Before being assisted back dining room ment was co mpleted into her chair, an assess that indic ated no injury. Codi ng: J1900A would be coded 1, one . Rat Slipping the floor is a fall. No injury was noted. ionale: to 2. Nurse’s notes describe a situation in which Ms. Z. went out with her family for dinner. When they returned, her son stated that while at the restaura nt, she f ell in the bathro om. No injury was noted when she returned from dinner. coded 1, one Codi ng: J1900A would be . ven if on outings, are captured here. Rat Falls ionale: the nursing hom e stay, e during 3. A nurse’s note describes a resident who, while being treated for pneumonia, climbed over his bedrails and fell to the floor. He had a cut over his left eye and som e swelling on his ar m. He ergency room was sent to the em , where X -rays revealed no injury and neurological checks revealed no chan ental status. ges in m Codi J1900B would be coded 1, one . ng: cept Lacerations and swelli ng without fractu Rat ionale: re are classified as injury (ex major). 34 October 2018 Page J-

424 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) A resident fell , lacerated his head, and head CT scan indicated a subdural hem ato ma. 4. 1, one J1900C would be Codi ng: . coded ma is a major injury. The injury occurred as a result of a ionale: Subdural hem ato Rat fa ll. 5. Mr. R. fell on his right hip in the facility on the ARD of his Quarterly MDS and complained of mild right hip pain. The initial x -ray of the hip did not show any injury. The nurse completed Mr. R’s Quarterly assessment and coded the assessment to reflect this Three days later, Mr. R. ent was submitted to QIES ASAP. information. The assessm complained of increasing pain and had difficulty ambulating, so a follow-up x-ray was done. The follow-up x-ray showed a hairline fracture of the right hip. This injury is noted by the physician to be attributed to the recent fall that occurred during the look-back period of the Quarterly assessment. Original Coding: coded 1, one . J1900B, Injury (except major) was Rationale: Mr. R. had a fall-related injury that caused him to complain of pain. Modification of Quarterly assessment: J1900B, Injury (except major) is coded 0, none and J1900C, Major Injury, is coded 1, one . Rationale: The extent of the injury did not pres ent itself right after the fall; however, it was directly related to the fall that occurred during the look-back period of the Quarterly assessment. Since the assessment had been submitted to QIES ASAP and the level of injury documented on the submitted Quarterly was now found to be different based on a repeat x -ray of the resident’s hip, the Quarterly assessment needed to be modified to accurately reflect the injury sustained during that fall. J2000: Prior Surgery Item Rat iona le Health Quality of Life -related • A recent history of major surgery during the 100 days prior to admission can affect a resident’s recovery. Planning for Care This item identifies whether the resident has had major surgery during the 100 days prior • story of major surgery can affect a resident’s recovery. to admission. A recent hi 35 October 2018 Page J-

425 CMS’s RAI Version 3.0 Manual CH 3: MDS Items [J] J2000: Prior Surgery (cont.) Step s f or Assessment 1. Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to admission. medical record to determine whether the resident had major surgery Review the resident’s 2. during the 100 days prior to admission. Medical record sources include medical records received from facilities where the resident received health care during the previous 100 days, the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available. Coding Instructions Code 0, No, • if the resident did not have major surgery during the 100 days prior to admission. Code 1, Yes, if the resident had major surgery during the 100 days prior to admission. • Code 8, Unknown, if it is unknown or cannot be determined whether the resident had • major surgery during the 100 days prior to admission. Coding Tips the • Generally, major surgery for item J2000 refers to a procedure that meets all following criteria: 1. the resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the skilled nursing facility (SNF), 2. the resident had general anesthesia during the procedure, and 3. the surgery carried some degree of risk to the resident’s life or the potential for severe disability. Examples Mrs. T reports that she required surgical removal of a skin tag from her neck a month and a 1. half ago. She had the procedure as an outpatient. Mrs. T reports no other surgeries in the last 100 days. Coding: J2000 would be coded 0, No . Mrs. T’s skin tag removal surgery did not require an acute care inpatient Rationale: stay, and general anesthesia was not administered; therefore, the skin tag removal does not meet all three required criteria to be coded as major surgery. Mrs. T did not have any other surgeries in the last 100 days. 36 October 2018 Page J-

426 CMS’s RAI Version 3.0 Manual MDS Items [J] CH 3: J2000: Prior Surgery (cont.) Mr. A’s wife informs his nurse that six months ago he was admitted to the hospital for five 2. days following a bowel resection (partial colectomy) for diverticulitis. Mr. A’s wife reports Mr. A has had no other surgeries since the time of his bowel resection. Coding: . 0, No J2000 would be coded Bowel resection is a major surgery requiring general anesthesia and has Rationale: some degree of risk for death or severe disability. Mr. A required a five -day hospitalization. However, the bowel resection did not occur in the last 100 days; it happened six months ago, and Mr. A has not undergone any surgery since that time. 3. Mrs. G. was admitted to the facility for wound care related to dehiscence of a surgi cal wound subsequent to a complicated cholecystectomy for which she received general anesthesia. The attending physician also noted diagnoses of anxiety, diabetes, and morbid obesity in her llowing a four -day acute medical record. She was transferred to the facility immediately fo care hospital stay. 1, Yes Coding: J2000 would be coded . Mrs. G underwent a complicated cholecystectomy for which she required Rationale: general anesthesia. She additionally had comorbid diagnoses of diabetes, morbid obesity, and anxiety contributing some additional degree of risk for death or severe disability. Mrs. G required a four on that occurred in the last 100 days. -day hospitalizati 37 October 2018 Page J-

427 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: ON K: SWAL WING/NUTRITION AL S TATUS SECTI LO o assess the many conditions tha Th ms in this se ction are inten ded t t co uld a ffect Intent: e ite s abi lity to m aintain adequate n utrition and hydration. Thi the resident’ ection cover s s s swallowing rs, h eight and weight, weight loss, and nutr itio nal ap pro aches. The a ssessor disorde e that borate w ian and diet ary s taff to ensur should colla ite ms in this se ction have ith the dietit been assesse d and calcul ated ac curat ely. K0100: Swall owi ng Disorder Item R at ionale Health-rel ated Quality of Life The abi lity t • ely can be aff ected by m any disease proces ses and functional o swallow saf decli ne. • Alter ations i n the ab ili ty to swallow c an resu lt in choking and aspir ation, which can incr he resident’ s risk for malnutrition, dehyd ration, and aspiration pneu monia. ease t Planning for Care • Care plan ning should include provisions f or monito ring the r esident during m ealti mes and during functions /activiti es th at include the consumption of food and liquids. speec ician, by the phys h language • When necessary, the re sident should be evalu ated py patholog erapist to as sess f or any n eed f or swal lowing thera l th ist and/or occupationa and/or to provide re commendations regarding t he consis ten cy of food and liquids. as not been hat h allowing disorder t ssess f or s igns and symptom s that suggest a sw A • fully tre ated or m success diet modif ications or ot her i nterventions (e.g., tube anaged with feeding, double swal low, turning hea d to swallo w, etc.) and theref ore r epresents a functional problem f or the resi dent. sident to • Care plan s hould be developed to a ssi st re low maintain safe and eff ect ive swal using compensatory techniques, a lter in diet consist enc y, and posit ioning during and ation eals. following m Steps for Asses sment Ask the re sident if he or she has had any di 1. ty swallowing during t he 7-day look- back ff icul period. Ask about each of the sy mptoms in K0100A through K0100D. Observe the resident duri ng m eals or at oth er times when he or she is e ating, drinking, or swallowing ine whether an y of the listed symptoms of possible s wallowing disord er to determ are ex hibi ted. 2. Inter view s taf f members on all shif ts who work with the res ident and ask if any of the four back p -day look- eriod. listed sy mptom s were evident d uring the 7 Page K October 2018 -1

428 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: all owi ng/Nutritional S K0100: Sw tatus (cont.) Review the m ian, die tician, and s peech lang uage 3. edical record, including nursing, physic ist notes, and a ny avai lable in formation on dental his tory or prob lem patholog s. Dental problems m de poor f itt ing dentures, den tal ca ries, edentulous, mouth sores, tum ors ay inclu and/or pa in with food consumption. Coding In str ucti on s Check all that apply. K0 When • 100A, l oss of l iquids/soli ds from mo uth wh en eati ng or drinki ng. or her mouth, the food or liquid dribbles down chin the resident has food or liquid in his or f alls o ut of the mouth. • th/che K0 100B, holding fo od in mou or r esidu eks al food in mou th a fter meals. Holding food in mouth or cheeks f or pro longed periods of tim e (s om eti mes ailed to em pty mouth labeled pocketin g) or food lef t in mouth becau se resident f completely. dur allowing 100C, coughi ng or ch oki ng K0 ing meals or when sw • medica tions. The res ore labored brea thin g, ident may cough or gag, turn red, have m or have di dent peak ing when eat ing, drinking, or taking m edications. The resi fficulty s may f requently co mplain of food or m edications “going down the wrong way.” allowing. • K0 100D, compl aints of di fficulty or pain with sw ay Resident m refuse food because it is icult to s wallo w. ful or diff pain n one of the 100Z, • above: if none of the K0100A through K0100D signs or K0 symptoms w ere p resent during the lo ok- back. Tips Coding • Do not code a swallowing problem when inte rve ntions have been succe ssful in t reating the problem and theref ore the s igns/ symptoms of the problem (K0100A through K0100D) did not occur during the 7-day look-back period. back p eriod. • Code even if the sy mptom occurred only once in the 7 -day look- K0200: Height and Weight Page K October 2018 -2

429 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: K0200: Height and Weight (cont.) Item R at ionale ated Quality of Life Health-rel fect tion al and hydration status can lead to debili ty th at can a • af Diminished nutri dversely and saf ety as well as qual ity of lif e. health Planning for Care Height and • easurem ents assist s taff with asses sing t he resi den t’s nutrition and weight m hydra atus by pro viding a m echanism for monitoring s tab ility of weight ove r a tion st period of time. The me asurement of weight is one guide for deter mining nutri tion al st atus. Steps for Assessment for K0200 A, Height y. 1. on the m ost recent heig ht sin ce the m ost re cent admission/entr y or ree ntr Base height Measure and record height in inches. 2. Measure height consistently ove r tim e in accordance with the f acil ity policy and procedure, which shoul d re flect cu rrent s tandar ds of pract ice (shoes off , etc.). edical r 3. essments, che ck t he m For subsequent ass ecord. If the last height recorded was m ore than one yea r ago, measure and r eco rd the resident’ s h eight a gain. Coding In str uct ion s for K 0200 A, Hei ght Record hei • ght to the nearest whole inch. easure • athem ati cal rounding (i.e., if height m m ment is X.5 inches or gr eat er, round Use nch. If heig ht measurement number is X.1 to X.4 height upward to the nearest whole i st w hole inch). F or example, a height of 62.5 inches would inches, round down to the neare be rounded to 63 inches and a heig ht of 62.4 inches would be rounded to 62 inches. Steps for Assessment for K0200B, Weight 1. Base weight on the m ost recent m easure in the l ast 30 days. 2. olicy and procedure, Measure w eight cons iste ntly ove r time in accordance with f aci lity p which shoul d re flect cu rrent s tandar ds of pract ice (shoes o ff, etc.). ent ass ithin 30 essments, che 3. For subsequ ght taken w the wei ck t he m edical record and enter days of ent. the ARD of this assessm 4. If the la st recorded wei ght was taken m ore than 30 days pri or to the ARD of this asse ssm ent or previous weight is n ot avai lab le, weigh the re sident again. ident’ 5. If the res ht was taken m s weig ore than o nce during the preceding month, record the most recent weight. Coding In str uct ion s for K 0200 B, Wei ght • Use m athem ati cal rounding (i.e., If weight is X.5 pounds [ lbs] or more, round weight hole pound. If weight is arest X.1 to X.4 lbs, round down to the ne upward to the near est w ample, a weight of 152.5 lbs would be rounded to 153 lbs and a whole pound). For ex weight of 152.4 lbs would be rounded to 152 lbs. Page K October 2018 -3

430 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: K0200: Height and Weight (cont.) • or e xample because of extr eme pain, i mmobilit y, or risk If a resi cannot be w eighed, f dent ra tionale ment information code (-) and docu ractures, use the standard no- of pathologi cal f on the resident’ s m edical r ecord. K0300: Weight Loss at ionale Item R DEFINITIONS 5% WEIGHT LOSS IN 30 Health-rel ated Quality of Life DAYS with resident’s the Start • Weight loss can result in debility and adversely affect weight closest to 30 days ago health, safety, and quality of life. it by .95 (or and multiply • For persons with morbid obesity, controlled and careful 95%). figure The resulting weight loss can improve mobility and health status. loss a 5% represents from For persons with a large volume (fluid) overload, • ago. 30 days the weight If the controlled and careful diuresis can improve health is weight resident’s current the to or less equal than status. resulting resident figure, the lost body than 5% more has Planning for Care weight. • m or of a change mportant indicat Weight loss ay be an i WEIGHT LOSS 10% IN in the resi den t’s health st atus or environm ent. DAYS 180 If signi ficant weight loss is noted, the inte rdis ciplinary • Start with the resident’s weight closest to 180 days changed or possible causes of should review f te am ago and multiply it by .90 (or intake, changed calori c need, change in m edica tion 90%). The resulting figure (e.g., diure tics), or changed fluid volum e st atus. represents a 10% loss from • Weight loss should be monitored on a contin uing basis; the weight 180 days ago. If we be asses uld ight loss sho t t he sed and care planned a the resident’s current weight tion ed until the next MDS tim e of not delay detec and is equal to or less than the ent. assessm resulting figure, the resident has lost 10% or more body Steps for Asses sment weight. riod with his or her weight ompares the r esident’s w eight in the current obs ervation pe This item c at two snapshots in t ime: At a point cl • osest to 30-days pre cedi ng the cu rrent weight. • At a point cl osest to 180- days pre ceding the cu nt weight. rre October 2018 Page K -4

431 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: ss (cont.) K0300: Weight Lo oes not consi der weight fluctuation ou tside of th ese two time points, although the This item d reside be monitored on a continual basis and weight l oss assessed and nt’s weight should addressed on the care plan as necess ary. For a New Admi ss ion DEFINITIONS ficant othe out weight ily, or signi sident, fam Ask the re 1. r ab PHYSICIAN - loss over the past 30 and 180 days. PRESCRIBED WEIGHT- s p ew trans Consult the resident’ hysic ian, revi fer 2. admission weight. pare with documentation, and com REGIMEN LOSS the previous weight, 3. If the ad mission weight is le ss than A weight reduction plan ordered resident’s by the the percentage of weight loss. calculate plan physician care the with he s am e process to d eterm ine and calculat e 4. Com plete t goal of weight reduction. May the weight co mission weight to weight loss mparing the ad employ -restricted a calorie 30 and 180 days ago. other diet or loss diets weight Also and exercise. includes For Sub sequent Assessmen ts planned It is diuresis. t’s weight in den mpare the resi co the me rec dical From 1. ord, is loss weight important that the curre nt observa tion period to his or h er we ight in the intentional. observation period 30 days ago. BODY MASS INDEX the the weight in ess than rrent weight is l If the cu 2. (BMI) lculate the p ercentage of observation period 30 days ago, ca from Number a calculated weight loss. person’s weight and height. 3. From the me dical rec ord, co mpare the resi den t’s weight in is used as a screening BMI tion period to his or h the curre nt observa ight in the er we identify tool to possible observation period 180 days ago. adults. for problems weight 4. the the weight in ess than rrent weight is l If the cu Visit observation period 180 days ago, c alculat e the percentage http://www.cdc.gov/healthyw of weight loss. eight/assessing/bmi/adult_b mi/index.html . Coding In ucti on s str Mathematic ally round weights as des cribed ction K0200B before completing the weight lo ss in Se calcul ation. • Code 0, no or u nkno wn: if the resident has not exper ienced weight loss of 5% or more in the pa st 30 days or 10% or more in the la st 1 80 days or if information about prior weight is not a lable. vai gim re -l oss eight scribed w sician-pre 1, y es on phy Code • sident if the re en: has exper oss of 5% or more in the past 30 days or 10% or more in the a weight l ienced s was plann ed and pursuant to a phy sician ’s ord er. In last 180 days, and the weight los cases w oss of 5% or more in 30 days or 10% or more in 180 here a resident has a weight l days as a resu lt of any physician or dered diet plan or expected w eight lo ss due to loss of rders for diur fluid with physic . 1 d as eti cs, K0300 can be code ian o -5 Page K October 2018

432 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: ss (cont.) K0300: Weight Lo Code 2, y es, not on physician-pr escrib ed w eight-l oss re • if the gimen: resident has ienced a weight l oss of 5% or more in the past 30 days or 10% or m ore exper oss was not planned and prescribed by a physi cian. in the last 180 days, and the weight l Coding Tips • A resident m ay expe rien ce weight variances in bet ween the s napshot time periods. Although these req uire follow up at t me, they are not captured on the MDS. he ti the f ident is losing a • ficant amount of w eight, If the res aci lity sho uld not wait for the signi 30- or 180-day ti mefram e to add ress the proble m. W eight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough as sessment of the resident’s nutri tion al status. • To code K0300 as 1, yes , the exp ressed goal of the weight loss diet or t he expected weight loss of edema through the use of diur eti cs must be docum ented. placed on a diabet low BMI is al BMI or even ic or • On occasio n, a resi dent with norm otherwise calorie-r In t his in stance, the intent of the diet is n ot to induce estricted diet. weight loss, and it would not be consi dered a phy sicia n-ord ered weight- loss regi men. Exa mples 1. Mrs. J has been on a phy sic ian ordered cal ori e-re str icted diet for the past year. She and her ion. Her cu physic greed to a pl an of weight reduct ian a rrent w eight is 169 lbs. Her we ight 30 days ago was 172 lbs. Her weight 180 days ago was 192 lbs. - prescribed weight Coding: coded 1, yes, on physician- K0300 would be loss regimen . Rat ionale : • 30- day c alculation: 172 x 0.95 = 163.4. Since the resident’s current w eight of than 163.4 lbs, which is the 5% point, 169 lbs is more has not she lost 5% bod y weight in the last 30 days. • 180- day c alculation: 192 .90 = 172.8. Since the resi den t’s curre nt wei ght of x lost 10% or m has ore 169 lbs is less than 172.8 lbs, which is the 10% point, she of body weight in the last 180 da ys. Page K October 2018 -6

433 CMS’s RAI Version MDS Items [K] 3.0 Manual CH 3: ei ght Lo ss ( K0300: W cont.) Mr. S has onths. His cur d incr easing need f or ass istance w ith eating o ver t he past 6 m rent 2. ha ys ago was 197 lbs. His 95 lbs. His weight 30 da weight is 1 weight 180 days ago was 185 lbs. coded 0, No Coding: K0300 would be . Rationale: 30- day calculation • x 0.95 = 187.15. Because the res ide nt’s cu rrent w eight : 197 of 195 lbs is m ch is the 5 % point, he h as not lost 5% ore than 187.15 lbs, whi he las ys. body weight in t t 30 da 180- day c alculat • . S’s cur rent weight of 195 lbs is g reater than his weight 180 ion: Mr days ago, so there is no need to c alculate his we ight loss. He has gained weight over this t ime period. rwent a BKA (below the knee a mputation). Her pr eoper ative weight 30 days ago 3. Ms. K unde 130 lbs. Her m ost recent pos was rative weig ht