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User Manual: G0600
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Accurately Assessing Functional Status and the MDS 3.0 Accurately Assessing Functional Status and the MDS 3.0 was developed as an educational program and reference for long-term care professionals. To the best of our knowledge, it reflects current federal regulations and practices. However, it cannot be considered absolute and universal. The information in this manual must be considered in light of the individual organization and state regulations. The authors and publisher disclaim responsibility for any adverse effect resulting directly or indirectly from the use of this manual, from any undetected errors, and from the user’s misunderstanding of the text. The authors and publisher put forth every effort to ensure that the content, including any policies, recommendations, and sample documents used in this text, were in agreement with current federal regulations, recommendations, and practices at the time of publication. The information provided in this course is subject to revision based on future updates and clarifications by CMS. The instructor commentary related to coding the MDS 3.0 contains the latest information released by CMS by the time of publication of this manual. Accurately Assessing Functional Status and the MDS 3.0 Rena R. Shephard, MHA, RN, RAC-MT, C-NE Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE IMPORTANT NOTICE Copyright © 2010, American Association of Nurse Assessment Coordination. All Rights Reserved. No part of this publication, excluding any government source documents, may be reproduced or transmitted in any form or by any means (electronic or mechanical, by photocopying or otherwise), without permission in writing from AANAC. For information contact AANAC, 400 S. Colorado Blvd., Suite 600, Denver, CO 80246. Phone: (800) 768-1880. Source documents printed in this manual are government documents that are not copyrighted and are available in the public domain. Published by AANAC Customer Service: (800) 768-1880 www.aanac.org Fax: (303) 758-3588 iii Table of Contents About the Authors and Expert Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . v AANAC and the Education/Certification Programs. . . . . . . . . . . . . . . . . . . . . . vii Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Course Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Pretest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 SNF Regulatory Mandate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 OBRA ’87 6 Comprehensive Assessment: The RAI Process 8 Use of MDS Data in the Survey Process and Public Quality-of-Care Reporting 10 Aging and Physical Functioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Common Disorders in Long-Term Care 12 Quiz 1: Aging and Physical Functioning 13 Evaluation of Physical Functioning and Structural Problems . . . . . . . . . . . . . . . . 14 Assessment of Musculoskeletal Problems 15 Quiz 2: Evaluation 17 MDS 3.0 Section G: Functional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Instructor Commentary—Intent 18 Supporting Documentation 20 G0110: Activities of Daily Living (ADL) Assistance 21 Quiz 3: Health-Related Quality of Life and Planning for Care 24 Quiz 4: ADL Coding Rules 49 G0120: Bathing 50 Quiz 5: Bathing 54 G0300: Balance During Transitions and Walking 55 Quiz 6: Balance During Transitions and Walking 66 G0400: Functional Limitation in Range of Motion 67 Quiz 7: Functional Limitation in Range of Motion 72 G0600: Mobility Devices 73 Quiz 8: Mobility Devices 75 G0900: Functional Rehabilitation Potential 76 Quiz 9: Functional Rehabilitation Potential 78 Care Planning for Functional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 The Survey Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Activities of Daily Living 89 Range of Motion 93 Prospective Payment System Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Pretest and Quiz Answer Keys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Resources and References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 iv Accurately Assessing Functional Status and the MDS 3.0 Source Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 MDS 3.0—Nursing Home Comprehensive (NC) Item Set 103 Care Area General Resources 141 Review of Indicators of ADLs—Functional Status/Rehabilitation Potential 142 Excerpts from Guidance to Surveyors—Activities of Daily Living 146 Excerpt from Guidance to Surveyors—Range of Motion 159 Form CMS-20066, Critical Elements for Activities of Daily Living (ADL) and/or Range of Motion (ROM) Status (Includes Cleanliness/Grooming and Positioning) 161 AANAC Training Manual Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 AANAC Membership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Accurately Assessing Functional Status and the MDS 3.0 v About the Authors Rena R. Shephard, MHA, RN, RAC-MT, C-NE Rena is the president of RRS Healthcare Consulting Services, providing LTC consulting and training services to facilities, corporations, and attorneys nationwide. She is the executive editor and the founding chair of AANAC and serves on the Master Teacher Editorial Advisory Board. Just since 2007, she has taught 17 of AANAC’s Resident Assessment Coordinator–Certified (RAC-CT®) workshops, presented at six AANAC national conferences, and authored or coauthored 26 of AANAC’s educational courses on MDS coding and nursing leadership. Nationally, Rena is a highly recognized expert in the RAI process and serves as a consultant to several of the CMS MDS-related projects, including MDS 3.0 development, and to California’s Quality Improvement Organization. She served as a DON in skilled nursing facilities for 14 years and has expertise in all aspects of long-term care. Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE Judy is one of AANAC’s exceptional Master Teachers for the RAC-CT® workshop and the author of and Master Teacher for AANAC’s newest workshop, Medicare University. Since 2007, she has presented several of AANAC’s RAC-CT workshops and, since 2009, numerous Medicare University workshops. Additionally, Judy has served as an expert reviewer for Introduction to Medicare Part A, MDS 3.0 Coding for OBRA and PPS, Resource Utilization Groups (RUG-IV) and the MDS 3.0, OBRA Timing and Scheduling for the MDS 3.0, and Care Planning and the MDS 3.0, in addition to being the coauthor of this course. She is a nationally recognized MDS/Medicare consultant and educator. Previously, she held positions as the RAI manager for Virginia and as a surveyor for Virginia. Judy has consulted CMS on several MDS projects and served on the CMS panel that authored and taught three national Webinars for providers and surveyors on MDS coding.
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2010:08:25 11:16:45-06:00, 2010:08:25 11:30:15-06:00, 2010:08:25 11:37-06:00, 2010:08:25 11:39:03-06:00, 2010:08:25 11:57:19-06:00, 2010:08:25 12:00:37-06:00, 2010:08:25 12:22:31-06:00, 2010:08:25 12:26:09-06:00, 2010:08:25 12:28:56-06:00, 2010:08:25 13:02:56-06:00, 2010:08:25 13:13:38-06:00, 2010:08:25 13:22:09-06:00, 2010:08:25 13:26:34-06:00, 2010:08:25 13:37:19-06:00, 2010:08:25 13:39:05-06:00, 2010:08:25 13:49:20-06:00, 2010:08:25 14:58:11-06:00, 2010:08:25 15:01:13-06:00, 2010:08:25 15:02:51-06:00, 2010:08:25 15:04:04-06:00, 2010:08:25 15:04:43-06:00, 2010:08:25 15:23:26-06:00, 2010:08:25 15:30:41-06:00, 2010:08:25 15:33:51-06:00, 2010:08:25 15:44:24-06:00, 2010:08:25 15:46:13-06:00, 2010:08:25 15:52:58-06:00, 2010:08:25 16:02:02-06:00, 2010:08:25 16:04:19-06:00, 2010:08:25 16:09:49-06:00, 2010:08:25 16:11:31-06:00, 2010:08:25 16:27:38-06:00, 2010:08:25 16:31:30-06:00, 2010:08:25 17:00:22-06:00, 2010:08:25 17:02:15-06:00, 2010:08:25 17:07:08-06:00, 2010:08:26 08:48:22-06:00, 2010:08:26 09:05:26-06:00, 2010:08:26 09:36:28-06:00, 2010:08:26 09:42:38-06:00, 2010:08:26 09:46:26-06:00, 2010:08:26 09:47:44-06:00, 2010:08:26 10:09:02-06:00, 2010:08:26 10:12:33-06:00, 2010:08:26 10:14:51-06:00, 2010:08:26 10:15:30-06:00, 2010:08:26 10:31:10-06:00, 2010:08:26 10:37:27-06:00, 2010:08:26 10:41:37-06:00, 2010:08:26 10:43:25-06:00, 2010:08:26 10:44:48-06:00, 2010:08:26 10:50:40-06:00, 2010:08:26 10:52:34-06:00, 2010:08:26 11:38:35-06:00, 2010:08:26 11:43:33-06:00, 2010:08:26 11:52:05-06:00, 2010:08:26 13:17:06-06:00, 2010:08:26 13:22:09-06:00, 2010:08:26 13:36:09-06:00, 2010:08:26 13:37:12-06:00, 2010:08:26 13:41:47-06:00, 2010:08:26 13:49:04-06:00, 2010:08:26 13:50:59-06:00, 2010:08:26 13:52:14-06:00, 2010:08:26 13:59:03-06:00, 2010:08:26 14:01:20-06:00, 2010:08:26 14:04:58-06:00, 2010:08:26 14:07:34-06:00, 2010:08:26 14:09:28-06:00, 2010:08:26 14:09:54-06:00, 2010:08:26 14:10:25-06:00, 2010:08:26 14:14:48-06:00, 2010:08:26 14:15:23-06:00, 2010:08:26 14:17:54-06:00, 2010:08:26 14:19:33-06:00, 2010:08:27 10:27:45-06:00, 2010:08:27 12:25:48-06:00, 2010:08:27 13:58:51-06:00, 2010:08:29 08:20:08-06:00, 2010:08:31 13:12:43-06:00, 2010:08:31 13:19:35-06:00, 2010:08:31 13:20:12-06:00, 2010:08:31 13:24:02-06:00, 2010:08:31 13:34:41-06:00, 2010:08:31 14:16:58-06:00, 2010:09:16 09:24:43-06:00, 2010:09:16 09:31:28-06:00, 2010:09:17 13:52:47-06:00, 2010:10:11 13:43:41-06:00, 2010:10:11 13:46:44-06:00, 2010:10:11 13:51:24-06:00, 2010:11:29 10:08:12-07:00, 2010:11:29 10:10:38-07:00, 2011:01:28 10:40:13-07:00, 2011:01:28 10:40:13-07:00, 2011:01:28 10:43:28-07:00, 2011:01:28 10:48:47-07:00, 2011:02:02 14:19:44-07:00, 2011:02:02 14:29:03-07:00, 2011:02:02 14:54:44-07:00, 2011:02:02 15:10:19-07:00, 2011:02:03 11:56:43-07:00, 2011:02:03 12:04:36-07:00, 2011:02:03 12:17:30-07:00, 2011:02:03 12:23:22-07:00, 2011:02:03 12:35:26-07:00, 2011:02:03 12:40:59-07:00, 2011:02:03 12:40:59-07:00, 2011:02:03 13:41:47-07:00, 2011:02:04 13:43:33-07:00, 2011:02:04 13:45:47-07:00, 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