WIXLIB

4/12/2019Toileting ProgramsConsulting Talent Training ResourcesScheduled toileting plans are formal plans thatmust be followed as indicated in the care plan The toileting plan/program must be residentspecific***don’t count check and change programs Bladder Training is a short termprogramThe goal is to reduce incontinentepisodes Pathway Health 201837MDS 3.0 RAI ManualConsulting Talent Training Resources“If the toileting program or bladderretraining leads to a decrease orresolution of incontinence, theprogram should be maintained.”CMS MDS 3.0 RAI Manual Page H-3 Pathway Health 201838Fecal IncontinenceConsulting Talent Training Resources Pathway Health 20183913

4/12/2019Fecal IncontinenceConsulting Talent Training ResourcesPotential Treatments/interventions (based upon thetype) of Fecal Incontinence Eating increased amounts of fiber; Drinking sufficient liquids; Use of medications to develop more solid stools that areeasier to control; Pelvic Floor Exercises and Biofeedback that strengthenthe pelvic floor muscles may improve bowel control. Surgery may be an option for fecal incontinence that failsto improve with other treatments or for fecal incontinencecaused by pelvic floor or anal sphincter muscle injuries; Electrical dance/Guidance/Manuals/downloads/som107ap pp guidelines ltcf.pdf Pathway Health 201840MDS Section HConsulting Talent Training ResourcesRemember, the MDS is not a primary sourcedocument, therefore, you will need evidence ofdocumentation to substantiate:A trial or current toileting program andresponse (H0200)How are you able to objectively determine (andprove by documentation) response to trial program ifcoded?Urinary IncontinenceDo you have a system to capture 7 days ofmonitoring for continence in order to code? Pathway Health 201841O0500 Restorative Nursing MDSConsulting Talent Training ResourcesIn order to code Section O0500 for RestorativeNursing Programs, there must be documentedevidence in the medical record for at least 15minutes/day for each program during the ARDlook back period. (We need to documentactual minutes) Pathway Health 20184214

4/12/2019Consulting Talent Training ResourcesDocumentation toSubstantiateProgramImplementationand MDS Coding43 Pathway Health 201843MDS Coding DocumentationConsulting Talent Training ResourcesSection G: ADL Documentation Identifies the need for the program Need to have “proof” during the observationperiod All shifts Include # episodes Ensure staff understand the MDS 3.0 RAIManual definitions/instructions44 Pathway Health 201844ADL CodingConsulting Talent Training ResourcesIt is imperative that the ADL trackingsubstantiates the MDS Coding. Remember,the MDS gathers information on the resident’sactual function - not what staff think theresident can do.45 Pathway Health 20184515

4/12/2019ADL Coding for the MDS 3.0Consulting Talent Training Resources It is imperative that the ADL documentationsubstantiates the MDS Coding.Remember, the MDS gathers information onthe resident’s actual function - not what staffthink the resident can do. Pathway Health 201846Implications of Section G:Consulting Talent Training ResourcesDollars/Reimbursement!! (Future Case Mix)Resident CareQuality Measures: One of the Quality Measuresthat potentially looks at Restorative includes:“Percent of residents whose need for help withactivities of daily living has increased.”Survey: What do surveyors look at when thereis a decline in ADL’s?47 Pathway Health 201847MDS 3.0 Section GGConsulting Talent Training Resources“Record the resident’s usual ability to perform self-care, indoor mobility(ambulation), stairs, and functional cognition prior to the current illness,exacerbation, or ualityInits/MDS30RAIManual.html Pathway Health 20184816

4/12/2019Section GG0130Consulting Talent Training Resources Assess the resident’s selfcare performance basedon direct observation, aswell as the resident’s selfreport and reports fromqualified clinicians, carestaff, or familydocumented in theresident’s medical recordduring the three-dayassessment period. Residents should beallowed to performactivities asindependently aspossible, as long as theyare safe. Pathway Health 201849Restorative Nursing and PDPMConsulting Talent Training ResourcesPDPM is the Patient Driven Payment Model Effective October 1, 2019 Will be used under the SNF Prospective Payment System (PPS) to classifySNF patients in a covered Part A stay (replacing RUG IV) Every resident will be categorized into a Nursing Component Similar to RUG-IV, all categories will have a Function Score based uponSection GG (not Section G) Still using Late Loss ADLs Similar to RUG-IV: Behavioral Symptoms & Cognitive Performance andReduced Physical Function categories have Restorative end splits. Draft guidance indicates:– 2 or more programs– Programs in O0500 require at least 15 min/day, 6 our of 7 days– Must be person-centered, written, communicated, evaluated and underthe direction of a licensed nurse Pathway Health 201850Restorative Nursing and PDPM Consulting Talent Training ResourcesIt is imperative that you have systems in place toevaluate and place a resident in an appropriateRestorative Program upon admission in order tocapture on the 5-Day Assessment!Why? The 5-day PPS Assessment (ARD days 1-8)pays all covered Part A days until Part Adischarge unless an Interim PaymentAssessment(IPA) is completed! Pathway Health 20185117

4/12/2019MDS O0500: RestorativeNursingConsulting Talent Training ResourcesThere will need to be documented evidence of15 or more minutes a day, in the 7 day lookback (observation period) for EACH programthat was performed Pathway Health 201852Overcoming ObstaclesConsulting Talent Training Resources53ObstaclesConsulting Talent Training Resources Staff doing more for the resident and not encouragingparticipation Unrecognized delirium Unrecognized pain or poor pain control Constipation Depression Inconsistent implementation of care plan interventions Fear Temporary Illness interruptions Resident choices/preferences Staffing pattern challengesThis document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 20185418

4/12/2019Consulting Talent Training ResourcesCommunicationEssentials withthe RestorativeNursing Programto PreventObstacles!55 Pathway Health 201855Consulting Talent Training ResourcesEDUCATIONALNEEDS OF THENURSINGSTAFF Pathway Health 201856C.N.A. EducationConsulting Talent Training Resources Purpose of Restorative Nursing Basic Components of the MDS Based RestorativeNursing Program C.N.A.’s need to be trained in the techniques thatpromote resident involvement in the activity Groups for Restorative Nursing Common Obstacles to Attainment of Restorative Goals Each Program is a separate, PLANNED event Activities and Tasks of each program, including skills andreturn demonstration Consistent implementation of care plan interventions Benefits of a Restorative Program57 Pathway Health 20185719

4/12/2019Nurse EducationConsulting Talent Training ResourcesExamples of Topics for education with nurses: Understanding of facility policies and procedures Understanding of state and federal regulations Ensuring follow-up with oversight on the unit forRestorative Nursing Observing Good Restorative Nursing Clinical Skills The importance of effective communication Ability to set positive examples How to complete effective unit rounds Successful use of a 24 hour report Pathway Health 201858Staff EducationConsulting Talent Training ResourcesPreparation for success1. Provide staff clear communication of expectations.2. Audit and monitor performance.3. Praise positive observations.4. Utilize information from audits to develop content for nursingmeetings.5. Be prepared to hold the nurses and C.N.A.’s accountable if they donot deliver!6. Remember consistency with all staff!7. Utilize objective observations for performance evaluations.8. Illicit and consider staff input.9. Enjoy your successes!59 Pathway Health 201859Consulting Talent Training Resources“Well-trained anddedicatedemployees are theonly sustainablesource ofcompetitivestrength”- Robert Reich60 Pathway Health 20186020

4/12/2019Person-Centered Interventions toBased on the ComprehensiveAssessment ProcessConsulting Talent Training Resources61Person Centered PLANNINGConsulting Talent Training ResourcesIf we follow the Process as it is INTENDED,Person Centered Care Planning is possible!! Admission Assessment Ancillary Assessments Resident/Family Involvement RAI Process Pathway Health 201862RAI ProcessConsulting Talent Training ResourcesCARE PLANCAA SUMMARYCAAsCATsMDSCARE ASSESSMENTSRESIDENT INTERVIEWS63 Pathway Health 20186321

4/12/2019Elements of a Solid RestorativeProgramConsulting Talent Training Resources64Elements of a Solid RestorativeConsultingProgram Talent Training Resources Policies and Procedures– Best Practice approach– Regulatory Compliance– Consistent with the RAI Process– Forms decision (paper, EHR?) Staff Education Relationship with Formal Therapy Program Implementation Oversight and Evaluation Revisions to the ProgramThis document is for general informational purposes only.It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 201865Consulting Talent Training ResourcesPROGRAMOVERSIGHT Pathway Health 20186622

4/12/2019Oversight and Review ofDocumentationConsulting Talent Training Resources C.N.A. Implementation Record/Flow Sheets ADL Documentation Minutes Tracking⃰ Daily review of documentation during theobservation period will help to ensure anyconcerns are addressed timely versus after theAssessment Reference Date! Pathway Health 201867Review of DocumentationConsulting Talent Training ResourcesOngoing review of documentation will alsoensure: Opportunities for on-the-spot education areaddressed Opportunities to address resident refusals in atimely manner (discussing risks/benefits andreason for refusals) Changes are made in a timely manner toresident needs and added to the care plan Pathway Health 201868ObservationsConsulting Talent Training ResourcesIt is recommended that the nurse in charge ofRestorative Nursing – Observes at least 2 programs/week. Keeps an updated, ongoing list of residents andtheir respective programs Observes all splints weekly (20%/day) Interviews resident’s and families regardingRestorative Programs Keeps track of educational status of employeesin regards to the Restorative Program Pathway Health 20186923

4/12/2019Documentation forRestorative NursingConsulting Talent Training Resources1. Assessment ProcessAncillary Assessments Range of Motion Functional ADL Bowel and Bladder BalanceMDS and CAA’s ADL’s Continence and Toileting Documentation Minutes of Restorative Programs Pathway Health 201870Documentation - continuedConsulting Talent Training Resources2. Person Centered Care Plan (original andrevisions)3. Implementation Records for C.N.A.’s4. C.N.A./Restorative Aide documentation5. Monthly Charting6. Change of Condition Charting7. Quarterly Review (progress, participation,resident response to programs over the quarter)8. State Specific charting - some states havespecific requirements. Pathway Health 201871Documentation: TherapyInvolvementConsulting Talent Training ResourcesFormal Communication (written and verbal)when Formal Therapy discharges resident fromtherapy to include: Current functional status Appropriate Goal Interventions⃰ Once therapy discharges and resident is in aRestorative Program, the program is underthe direction of nursing. Pathway Health 20187224

4/12/2019Putting it all TogetherConsulting Talent Training ResourcesOnce you have all of your data and assessmentinformation, a decision will be made on theprogram goals and interventions for eachindividual resident-includingRESIDENT/FAMILY input, a care plan iscompleted, C.N.A. documentation is preparedand communication is essential! Pathway Health 201873Consulting Talent Training ResourcesEffectiveAudit System Pathway Health 201874Audit of the Entire Program!Consulting Talent Training Resources Is there a formal restorative program in place? Has facility-wide training been completed for the RestorativeNursing Program Do you keep an up-to-date Restorative Nursing master list? Do you complete monthly and quarterly summaries of residentprogress, participation and resident response to eachprogram? Do you have in place functional assessments to identifybaseline and ongoing status? Are Restorative Nursing flow sheets available to trackimplementation each shift/day? Do care plans indicate person-centered goals andinterventions for the Restorative Nursing Program? Pathway Health 20187525

4/12/2019Example of Program AuditConsulting Talent Training Resources Pathway Health 201876Action PlanningConsulting Talent Training Resources Pathway Health 201877In Summary--Consulting Talent Training ResourcesThe Basic Components of a RestorativeProgram Include:1. Policy and Procedure Management2. Review and Selection of Forms3. Assessment Process: Identification of a need forthe program based on assessment, resident inputand ADL deficit4. Determination of which program the resident isappropriate for5. Ensure that the program is a separate,individualized, care planned program Pathway Health 20187826

4/12/2019In Summary (continued)Consulting Talent Training Resources6. Documentation needs to substantiate theprogram need and implementation7. Ongoing monitoring and re-evaluation isnecessary to determine resident centeredadjustments for quality8. Staff education and competence*Skills checklists, competency evaluations, etc.9. Oversight and audits for compliance10.Quality Assurance/QAPI Pathway Health 201879References:Consulting Talent Training ResourcesMDS 3.0 RAI Manual: s/mds30raimanual.htmlCMS, State Operations Manual, Appendix PP: ce/Manuals/downloads/som107ap pp guidelines ltcf.pdf Pathway Health 201880Revitalize Your RestorativeNursing Program for Success!Lisa ThomsonChief Strategy Officerwww.pathwayhealth.comConsulting Talent Training Resources8127

4/12/2019DisclaimerConsulting Talent Training Resources“This presentation provided is copyrightedinformation of Pathway Health. Please note thepresentation date on the title page in relation tothe need to verify any new updates andresources that were listed in thispresentation. This presentation is intended tobe informational. The information does notconstitute either legal or professionalconsultation. This presentation is not to be soldor reused without written authorization ofPathway Health.” Pathway Health 20188228

"Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning." - MDS 3.0, RAI Manual, Pg. 0-36 9 7 8 9