Section 147.200  Minimum Data Set (MDS) On-Site Review Documentation

 

a)         Pursuant to Section 147.175, Department staff shall conduct on-site reviews of Minimum Data Set (MDS) data to determine the accuracy of resident information that is relevant to the determination of reimbursement rates. 

 

1)         Department staff shall request in writing the current charts of individual residents needed to begin the review process.  Current charts and completed MDSs for the previous 15 months shall be provided to the review team within an hour after this request.  Additional documentation regarding reimbursement areas for the identified Assessment Reference Date (ARD) timeframe shall be provided to the review team within four hours after the initial request.

 

2)         When further documentation is needed by the review team to validate an area, the team will identify the area of reimbursement requiring additional documentation and provide the facility with the opportunity to produce that information.  The facility shall provide the team with the additional documentation within 24 hours after the initial request.  All documentation that is to be considered for validation must be provided to the team prior to exit. 

 

3)         Pursuant to 89 Ill. Adm. Code 140.12(f), the facility shall provide Department staff with access to residents, professional and non-licensed direct care staff, facility assessors, clinical records and completed resident assessment instruments, as well as other documentation regarding residents' care needs and treatments.

 

4)         Failure to provide timely access to records may result in suspension or termination of a facility's provider agreement in accordance with 89 Ill. Adm. Code 140.16(a)(4). 

 

5)         Some states may have regulations that require supportive documentation elsewhere in the record to substantiate the resident's status on particular MDS items used to calculate payment under the State's Medicaid system (RAI Manual, page 1-24).  These additional documentation requirements shall be met for reimbursement. 

 

6)         The Department shall provide for a program of delegated utilization review and quality assurance.  The Department may contract with medical peer review organizations to provide utilization review and quality assurance.

 

b)         There shall be documentation in the resident's record to support an MDS coded response indicating that the condition or activity was present or occurred during the observation or look back period.  Directions provided by the RAI User's Manual (as described in Section 147.125) are the basis for all coding of the MDS.  Section S is reserved for additional State-defined items.  All documentation requirements pertain to the MDS 2.0 and Section S items.

 

c)         Each nursing facility shall ensure that MDS data for each resident accurately and completely describes the resident's condition, as documented in the resident's clinical records, maintained by the nursing facility, and the clinical records shall be current, accurate and in sufficient detail to support the reported resident data.

 

d)         Documentation guidance has been compiled from the RAI Manual, instructions that are present on the MDS 2.0 form itself, RAI-MH, and Illinois additional documentation requirements.  If later guidance is released by CMS that contradicts or augments guidance provided in this Section, the more current information from CMS becomes the acceptable standard.  If additional ICD-9 codes are published, they will be reviewed for appropriateness.

 

e)         Documentation from all disciplines and all portions of the resident's clinical record may be used to verify an MDS item response.  All supporting documentation shall be found in the facility during an on-site visit.

 

f)          All conditions or treatments shall have been present or occurred within the designated observation period.  Documentation in the clinical record shall consistently support the item response and reflect care related to the symptom/problem.  Documentation shall apply to the appropriate observation period and reflect the resident's status on all shifts.  In addition, the problems that are identified by the MDS item responses that affect the resident's status shall be addressed on the care plan.  Insufficient or inaccurate documentation may result in a determination that the MDS item response submitted could not be validated.

 

g)         Disease Diagnoses.  Throughout Table A, when a diagnosis is required, the following must be met:

 

1)         Code only those diseases or infections that have a relationship to the resident's current ADL (Activities of Daily Living) status, cognitive status, mood or behavior status, medical treatments, nursing monitoring or risk of death as directed in the RAI Manual.

 

2)         The disease conditions require a physician-documented diagnosis in the clinical record.  It is good clinical practice to have the resident's physician provide supporting documentation for any diagnosis.

 

3)         Do not include conditions that have been resolved or no longer affect the resident's functioning or care plan.  One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's health status.

 

h)         Activities of Daily Living (ADL).

 

1)         Facilities shall maintain documentation that supports the coding of Section G, Physical Functioning, and Structural Problems on the MDS during the look-back period.  The documentation shall show the MDS coded level of resident self-performance and support has been met.

 

2)         Documentation shall be dated within the look-back period and must contain information from all three shifts that clearly supports the level of self-performance and support needed.

 

3)         When there is a widespread lack of supporting documentation as described in subsections (h)(1) and (2), the ADL scores for the residents lacking documentation will be reset to zero.

 

4)         When there is an occasional absence of documentation for residents in the sample, ADL scores will be based on the observation and/or interview of the resident and facility staff at the time of the review.  If the resident has been discharged and there is no documentation to support the ADL coding, ADL scores will be reset to one.

 

i)          Restorative services are programs under the direction and supervision of a licensed nurse and are provided by nursing staff.  The programs are designed to promote the resident's ability to adapt and adjust to living as independently and safely as possible.  The focus is on achieving and/or maintaining optimal physical, mental, and psychosocial functioning.  A program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated.  Although therapists may participate in designing the initial program, members of nursing staff are still responsible for the overall coordination and supervision of restorative nursing programs.  Staff completing the programs shall be communicating progress, maintenance, regression and other issues/concerns to the licensed nurse overseeing the programs.  To qualify for reimbursement, the provision of restorative programs shall meet the following criteria for each program identified for reimbursement:

 

1)         When programs are designed using verbal cueing as the only intervention, documentation and/or observation must support the following:

 

A)        Without such cueing the resident would be unable to complete the required ADL task.

 

B)        The verbal interventions are aimed at providing the resident with instructions for completing the task in such a way that promotes the resident's safety and awareness.

 

C)        Verbal interventions that are simply reminders to complete the task may not be the sole content of the program.

 

2)         Documentation shall clearly define the resident's need for the program and the defined program shall correspond to the identified need of the resident. Observation and/or interview shall also support the need for the program. 

 

3)         The clinical record shall identify a restorative nursing plan of care to assist the resident in reaching and/or maintaining his or her highest level of functioning.  Staff completing the programs shall be aware of the program and the resident's need for the program.

 

4)         Documentation must support that the program was reevaluated and goals and interventions were revised as necessary to assist the resident in reaching and/or maintaining his or her highest level of functioning.

 

5)         Documentation shall contain objective and measurable information so that progress, maintenance or regression can be recognized from one report to the next.

 

6)         Goals shall be resident specific, realistic, and measurable.  Goals shall be revised as necessary.  Revisions shall be made based on the resident's response to the program.

 

7)         The resident's ability to participate in the program shall be addressed.

 

8)         Written evidence of measurable objectives and interventions shall be in the restorative plan of care and be individualized to the resident's problems and needs.  There shall be evidence the objectives and interventions were reviewed quarterly and revised as necessary.

 

9)         There shall be evidence of quarterly evaluation written by a licensed nurse in the clinical record.  The evaluation must assess the resident's progress and participation in the program since the last evaluation.  It shall contain specific information that includes the resident's response to the program (i.e., amount of assistance required, devices used, the distance, the progress made, how well the resident tolerated the program).  An evaluation shall be documented on each restorative program the resident is receiving.

 

10)         There shall be written evidence that staff carrying out the programs have been trained in techniques that promote resident involvement in the activity.

           

11)         If volunteers or other staff were assigned to work with specific residents, there shall be written evidence of specific training in restorative techniques that promote the resident's involvement in the restorative program.

 

12)         There shall be documentation to support that the programs are ongoing and administered as planned outside the look-back period, unless there is written justification in the clinical record that supports the need to discontinue the program.  Observation and/or interviews must also support that the programs are ongoing and administered as planned.

 

13)         If a restorative program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, duration and frequency as part of the care planning process.  The results of this reassessment shall be documented in the record.

 

14)         The actual number of minutes per day spent in a restorative program shall be documented for each resident and for each restorative program during the look-back period.

 

15)         The Department designated endurance assessment must be completed quarterly on each resident receiving two or more restorative programs.  A licensed nurse must complete this assessment.

 

16)         A resident coded as totally dependent in an ADL function will only be reimbursed for one quarter for the following corresponding restorative programs:  bed mobility, transfer, walking, dressing/grooming, and/or eating/swallowing.

 

17)         A resident scoring and/or receiving hospice services shall not be eligible for the following restorative programs:  bed mobility, transfer, walking, dressing/grooming, eating and/or other restoratives.

 

18)         When multiple restoratives are coded in a facility, the staff levels must support the ability to deliver these programs based on the number and frequency of programs coded.

 

19)         All restorative programs shall meet the specifications of the RAI Manual for the individual restoratives. 

 

j)          Passive Range of Motion (PROM).

 

1)         The restorative program shall meet the definition of PROM as identified in the RAI Manual.

 

2)         The PROM program shall address the functional limitations identified in section G4 of the MDS.

 

3)         There shall be evidence that the program is planned and scheduled.  PROM that is incidental to dressing, bathing, etc., does not count as part of a formal restorative program.

             

k)         Active Range of Motion (AROM).

 

1)         The restorative program meets the definition of AROM as identified in the RAI Manual.

 

2)         The AROM programs shall address the functional limitations identified in section G4 of the MDS.

 

3)         There shall be evidence that the program is planned and scheduled.  AROM that is incidental to dressing, bathing, etc., does not count as part of a formal restorative program.

 

4)         AROM does not include exercise groups with more than four residents assigned per supervising helper or caregiver.

             

l)          Splint/Brace Assistance.  A splint or brace is defined as an appliance for the fixation, union, or protection of an injured part of the body.

 

m)       Dressing or Grooming Restorative.  Grooming programs, including programs to help the resident learn to apply make-up, may be considered restorative nursing programs when conducted by a member of the activity staff.  These programs shall have goals, objectives, and documentation of progress and be related to the identified deficit.

             

n)         Scheduled Toileting.

 

1)         The program shall have documentation to support that all the requirements identified in the RAI Manual are met.

 

2)         The description of the plan shall be documented, including:  frequency, reason, and response to the program.

 

3)         The plan shall be periodically evaluated and revised, as necessary, including documentation of the resident's response to the plan.

 

4)         This does not include a "check and change" program or routine changing of the resident's incontinent briefs, pads or linens when wet, when there is no participation in the plan by the resident.

 

5)         There shall be documentation to support the deficit in toileting and/or the episodes of incontinence. 

 

6)         A resident scoring S1 = 1 (meets Subpart S criteria) shall have a corresponding diagnosis of cerebral vascular accident (CVA) or multiple sclerosis to qualify for reimbursement in scheduled toileting.

 

o)         Continence Care.

 

1)         Documentation shall support that catheter care was administered during the look-back period.

 

2)         The type and frequency of the care shall be documented. 

 

3)         Documentation shall support that the RAI requirements for a bladder retraining program were administered during the look-back period.

 

4)         The resident's level of incontinence shall be documented during the look- back period to support the bladder retraining program.

 

5)         Bladder scanners cannot be the sole content of the bladder retraining program.

             

p)         Pressure Ulcer Prevention.

 

1)         Documentation shall support the history of resolved ulcer in the identified timeframe and/or the use of the coded interventions during the identified timeframe.

 

2)         Interventions and treatments shall meet the RAI definitions for coding. 

 

3)         Documentation shall support a specific approach that is organized, planned, monitored and evaluated for coding a turning and positioning program. 

 

4)         There shall be documentation that the resident was assessed related to his or her risk for developing ulcers.  A resident assessed to be at high risk shall have interventions identified in the plan of care.

                                                 

q)         Moderate Skin Care/Intensive Skin Care.

 

1)         Interventions and treatments shall meet the RAI definitions for coding.

 

2)         Documentation of ulcers shall include staging as the ulcers appear during the look-back period.

 

3)         Documentation of ulcers shall include a detailed description that includes, but is not limited to, the stage of the ulcer, the size, the location, any interventions and treatments used during the look-back period.

 

4)         Documentation of burns shall include, but is not limited to, the location, degree, extent, interventions and treatments during the look-back period.

 

5)         Documentation of open lesions shall include, but is not limited to, location, size, depth, any drainage, interventions and treatments during the look-back period.

 

6)         Documentation of surgical wounds shall include, but is not limited to, type, location, size, depth, interventions and treatment during the look-back period.

 

7)         All treatments involving M5e, M5f, M5g, and M5h shall have a physician's order with the intervention and frequency.

 

8)         Documentation to support that the intervention was delivered during the look-back period shall be included.

 

9)         Documentation of infection of the foot shall contain a description of the area and the location.

 

10)        Documentation shall support a specific approach that is organized, planned, monitored and evaluated for coding a turning and positioning program.

 

11)        Documentation for items coded in M4 shall include documentation of an intervention, treatment, and/or monitoring of the problem or condition identified.

 

r)          IV Therapy.

 

1)         Documentation shall include the date delivered, type of medication and method of administration.

 

2)         Documentation shall support monitoring of an acute medical condition (physical or psychiatric illness) by a licensed nurse as required in subsection (y) of this Section.

                                                             

s)         Injections.  Documentation shall include the drug, route given and dates given.

 

t)          Oxygen Therapy.  Documentation shall include a physician's order and the method of administration and date given.

 

u)         Chemotherapy.  Documentation shall support the resident was monitored for response to the chemotherapy.

 

v)         Dialysis.  Documentation shall support the resident was monitored for response to the dialysis.

 

w)        Blood Glucose Monitoring.

 

1)         Documentation shall support that RAI criteria for coding a diagnosis was met, including a physician documented diagnosis.

 

2)         Documentation shall support coding of a therapeutic diet being ordered and given to the resident.

 

3)         Documentation shall support coding of a dietary supplement being ordered and given to the resident during the look-back period.  There shall be evidence to support it was not part of a unit's daily routine for all residents.

 

4)         Documentation shall support the coding that injections were given the entire seven days of the look-back period.

 

x)         Infectious Disease.

 

1)         Documentation shall support that the criteria defined in the RAI Manual for coding this subsection were met.

 

2)         Documentation shall support the active diagnosis by the physician and shall include signs and symptoms of the illness.

 

3)         Interventions and treatments shall be documented.

 

4)         Documentation shall support that all RAI requirements for coding a Urinary Tract Infection (UTI) are met.

 

5)         Administration of maintenance medication to prevent further acute episodes of UTI is not sufficient to code I2j.

 

y)         Acute Medical Conditions.

 

1)         Documentation shall support that the RAI requirements for coding these areas are met.

 

2)         Documentation shall support monitoring of an acute medical condition (physical or psychiatric illness) by a licensed nurse.

 

3)         There shall be evidence that the physician has evaluated and identified the medically unstable or acute condition for which clinical monitoring is needed.

 

4)         There shall be evidence of significant increase in licensed nursing monitoring.

 

5)         There shall be evidence that the episode meets the definition of acute, which is usually of sudden onset and time-limited course.

 

z)         Pain Management.

 

1)         There shall be documentation to support the resident's pain experience during the look-back period and that interventions for pain were offered and/or given.

 

2)         Residents shall be assessed in a consistent, uniform and standardized process to measure and assess pain. 

 

aa)       Discharge Planning.

 

1)         Social services shall document monthly the resident's potential for discharge, specific steps being taken toward discharge, and the progress being made.

 

2)         Social service documentation shall demonstrate realistic evaluation, planning, and follow-through.

 

3)         Discharge plans shall address the current functional status of the resident, medical nursing needs, and the availability of family and/or community resources to meet the needs of the resident.

 

bb)       Nutrition.

 

1)         Documentation shall support coding of tube feeding during the look-back period.

 

2)         Intake and output records and caloric count shall be documented to support the coding of K6.

 

3)         Documentation of a planned weight change shall include a diet order and a documented purpose or goal that is to facilitate weight gain or loss.

 

4)         Documentation of a dietary supplement shall include evidence that resident received the supplement and that it was ordered and given between meals.

 

cc)       Hydration.

 

1)         Documentation shall support that the resident passes two or fewer bowel movements per week, or strains more than one of four times when having a bowel movement during the look-back period to support the coding of H2b.

 

2)         Documentation shall support that the resident received a diuretic medication during the look-back period to support the coding of O4e.

 

3)         Documentation shall include frequency of episodes and accompanying symptoms to support the coding of vomiting.

 

4)         Documentation shall include signs and symptoms, interventions and treatments used to support the coding of volume depletion, dehydration or hypovolemia.

 

5)         There shall be documentation of temperature to support the coding of fever.

 

6)         There shall be documentation to support the coding of internal bleeding that shall include the source, characteristics and description of the bleeding.

 

7)         There shall be documentation that interventions were implemented related to the problem identified.

 

dd)       Psychosocial Adaptation.  Psychosocial adaptation is intended for residents who require a behavior symptom evaluation program or group therapy to assist them in dealing with a variety of mood or behavioral issues.  The criteria for reimbursement in this area requires both an intervention program and the identification of mood or behavioral issues. Residents shall be assessed for mood and behavioral issues and interventions shall be implemented to assist the resident in dealing with the identified issues.  To qualify for reimbursement in this area, the facility must meet the following criteria:

 

1)         Criteria for a special behavior symptom evaluation program.

 

A)        There must be documentation to support that the program is an ongoing and comprehensive evaluation of behavior symptoms.

 

B)        Documentation must support the resident's need for the program.

 

C)        The documentation must show that the purpose of the program is to attempt to understand the "meaning" behind the resident's identified mood or behavioral issues.

 

D)        Interventions related to the identified issues must be documented in the care plan.

 

E)         The care plan shall have interventions aimed at reducing the distressing symptoms.

 

2)         Criteria for group therapy.

 

A)        There is documentation the resident regularly attends sessions at least weekly.

 

B)        Documentation supports that the therapy is aimed at helping reduce loneliness, isolation, and the sense that one's problems are unique and difficult to solve. 

 

C)        This area does not include group recreational or leisure activities.

 

D)        The therapy and interventions are addressed in the care plan.

 

E)         This must be a separate session and cannot be conducted as part of skills training.

 

3)         Criteria for indicators of depression.

 

A)        There must be documentation to support that identified indicators occurred during the look-back period.

 

B)        The documentation shall support the frequency of the indicators as coded during the look-back period.

 

C)        There shall be documentation to support that interventions were implemented to assist the resident in dealing with these issues.

 

4)         Criteria for sense of initiative/involvement.

 

A)        There is documentation to support the resident was not involved or did not appear at ease with others or activities during the look-back period.

 

B)        There shall be evidence that interventions were implemented to assist the resident in dealing with these issues.

 

5)         Criteria for unsettled relationships/past roles.

 

A)        There is documentation to support the issues coded in this area during the look-back period.

 

B)        There shall be evidence that interventions were implemented to assist the resident in dealing with the issues identified.

 

6)         Criteria for behavioral symptoms.

 

A)        There is documentation to support that the behaviors occurred during the look-back period and the interventions used.

 

B)        Documentation should reflect the resident's status and response to interventions.

 

C)        Documentation should include a description of the behavior exhibited and the dates it occurred, as well as staff response to the behaviors.

 

D)        Documentation supporting that the behaviors coded meet the RAI definitions for the identified behavior.

 

E)         The care plan identifies the behaviors and the interventions to the behaviors.

 

7)         Criteria for delusions/hallucinations.

 

A)        There is documentation to support that the delusions or hallucinations occurred during the look-back period.

 

B)        Documentation contains a description of the delusion or hallucinations the resident was experiencing.

 

C)        There is documentation to support the interventions used.

 

ee)       Psychotropic Medication Monitoring.

Documentation shall support the facility followed the documentation guidelines as directed by 42 CFR 483.25(l), Unnecessary drugs (State Operations Manual F-tag F329).

 

ff)         Psychiatric Services (Section S).

 

1)         There shall be evidence the resident met IDPH Subpart S criteria during the look-back period.

 

2)         There shall be evidence a pre-admission screening completed by a Department of Human Services-Division of Mental Health screening entity was completed on the resident that identifies the resident as having a serious mental illness (SMI).

 

3)         Ancillary provider services are services that are provided by direct non-facility psychiatric service providers in order to meet 77 Ill. Adm. Code 300, Subpart S requirements.

 

4)         Psychiatric rehabilitation services that are provided by non-facility providers or an outside entity shall meet the needs of the SMI resident as determined by the resident's individual treatment plan (ITP).

 

5)         Facilities must ensure compliance with 77 Ill. Adm. Code 300.4050 when utilizing non-facility or outside ancillary providers.

 

6)         Adjustments in the rate for utilization of ancillary providers shall be calculated based upon Department claims data for ancillary provider billing.

 

gg)       Skills Training.  Skills training is specific methods for assisting residents who need and can benefit from this training to address identified deficits and reach personal and clinical goals.  To qualify for reimbursement, the provision of skills training shall meet all of the following criteria:

 

1)         Skills and capabilities shall be assessed with the use of a standardized skills assessment, a cognitive assessment and an assessment of motivational potential.  The assessment of motivational potential will assist in determining the type and size of the group in which a resident is capable of learning.

 

2)         Addresses identified skill deficits related to goals noted in the treatment plan.

 

3)         Skills training shall be provided by staff that are paid by the facility and have been trained in leading skills groups by a Department approved trainer.

 

4)         Training shall be provided in a private room with no other programs or activities going on at the same time.  The environment shall be conducive to learning in terms of comfort, noise, and other distractions.

 

5)         Training shall be provided in groups no larger than ten, with reduced group size for residents requiring special attention due to cognitive, motivational or clinical issues, as determined by the skills assessment, cognition and motivational potential.  Individual sessions can be provided as appropriate and shall be identified in the care plan.

 

6)         Training shall utilize a well-developed, structured curriculum and specific written content developed in advance to guide each of the sessions.  (Published skills modules developed for the severe mentally ill (SMI) and Mental Illness/Substance Abuse (MISA) populations are available for use and as models.)

 

7)         The curriculum shall address discrete sets of skill competencies, breaking skills down into smaller components or steps in relation to residents' learning needs.

 

8)         The specific written content shall provide the rationale for learning, connecting skill acquisition to resident goals.

 

9)         Training shall employ skill demonstration/modeling, auditory and visual presentation methods, role-playing and skill practice, immediate positive and corrective feedback, frequent repetition of new material, practice assignments between training sessions (homework), and brief review of material from each previous session.

 

10)          There shall be opportunities for cued skill practice and generalization outside session as identified in the care plan and at least weekly documentation relative to skill acquisition.

 

11)          Each training session shall be provided and attended in increments of a minimum of 30 minutes each (not counting time to assemble and settle) at least three times per week.  Occasional absences are allowable, with individual coverage of missed material as necessary.  However, on-going 1:1 training shall not qualify under this area.

 

hh)       Close or Constant Observations.

 

1)         Coding of this item is intended only for interventions applied in response to the specific current significant need of an individual resident.  This item shall not be coded for observation conducted as standard facility policy for all residents, such as for all new admissions, or as part of routine facility procedures, such as for all returns from hospital, or as a part of periodic resident headcounts.

 

2)         There shall be documentation for the reason for use, confirmation that the procedure was performed as coded with staff initials at appropriate intervals, brief explanation of the resident's condition and reason for terminating the observation.

 

ii)         Cognitive Impairment/Memory Assistance Services.

 

1)         Documentation shall include a description of the resident's short-term memory problems.

 

2)         A method of assessing and determining the short-term memory problem shall be documented.

 

3)         Documentation shall include a description of the resident's ability to make everyday decisions about tasks or activities of daily living. 

 

4)         Documentation shall include a description of the resident's ability to make himself or herself understood.

 

jj)         Dementia Care Unit.

 

1)         Unit was Illinois Department of Public Health certified during look-back period.

 

2)         Resident resided in the unit during the look-back period.

 

3)         Activity programming is planned and provided seven days a week for an average of eight hours per day.

 

4)         Required assessments were completed on the resident.

 

5)         If the resident has a Cognitive Performance Scale (CPS) score of five, care planning shall address the resident's participation in the unit's activities.

 

6)         If a particular resident does not participate in at least an average of four activities per day over a one-week period, the unit director shall evaluate the resident's participation and have the available activities modified and/or consult with the interdisciplinary team.

 

7)         Documentation shall support staff's efforts to involve the resident.

 

kk)       Exceptional Care Services.

 

1)         Respiratory Services.

 

A)        A respiratory therapist shall evaluate the status of the resident at least monthly if the resident has a tracheostomy.

 

B)        Documentation of respiratory therapy being provided 15 minutes a day shall be present in the clinical record for the look-back period.

 

C)        Documentation of a physician's orders for the treatments.

 

D)        Respiratory therapy requires documentation in the record of the treatment and the times given by a qualified professional (respiratory therapist or trained nurse) as defined in the RAI Manual.

 

E)         Documentation of suctioning includes type, frequency and results of suctioning.

 

F)         Documentation of trach care includes type, frequency and description of the care provided.

 

2)         Weaning From Ventilator.

Documentation shall be in place to support weaning from the ventilator.

 

3)         Morbid Obesity.

 

A)        A dietician's evaluation shall be completed with evidence of on-going consultation.

 

B)        On-going monitoring of weight shall be evident.

 

C)        The psychosocial needs related to weight issues shall be identified and addressed.         

 

4)         Complex Wounds.

Facilities are to follow documentation guidelines as directed by 42 CFR 483.25(c) (State Operations Manual F-tag F314).  All documentation requirements listed in F314 shall be met.

 

5)         Traumatic Brain Injury (TBI).

 

A)        Documentation shall support that psychological therapy is being delivered by licensed mental health professionals, as described in the RAI Manual.

 

B)        Documentation shall support a special symptom evaluation program as an ongoing, comprehensive, interdisciplinary evaluation of behavioral symptoms as described in the RAI Manual.

 

C)        Documentation shall support evaluation by a licensed mental health specialist in the last 90 days.  This shall include an assessment of a mood, behavioral disorder, or other mental health problems by a qualified clinical professional as described in the RAI Manual.

 

D)        The care plan shall address the behaviors of the resident and the interventions used.

 

ll)         Accident/Fall Prevention.

 

1)         Documentation shall support that the resident has the risk factor identified on the MDS.

 

2)         Documentation shall support that the resident has been assessed for fall risks.

 

3)         If the resident is identified as high risk for falls, documentation shall support that interventions have been identified and implemented.

 

mm)     Restraint Free.

 

1)         There shall be documentation to support the previous use of a restraint and the resident response to the restraint.

 

2)         There shall be evidence that the restraint was discontinued.

 

nn)       Clarification and additional documentation requirements are as follows:

 

1)         Defined actions such as further assessment or documentation, described in the RAI Manual as "good clinical practice", are required by the Department as supporting documentation.  Clinical documentation that contributes to identification and communication of a resident's problems, needs and strengths, that monitors his or her condition on an on-going basis, and that records treatments and response to treatment is a matter of good clinical practice and is an expectation of trained and licensed health care professionals (RAI page 1−23).

 

2)         The facility shall have in place policies and procedures to address specific care needs of the residents, written evidence of ongoing in-services for staff related to residents' specific care needs and all necessary durable medical equipment to sustain life and carry out the plan of care as designed by the physician.  In the absence of these items, a referral will be made to the Illinois Department of Public Health.

 

3)         No specific types of documentation or specific forms are mandated, but documentation shall be sufficient to support the codes recorded on the MDS.  Treatments and services ordered and coded shall be documented as delivered in the clinical record.

 

4)         When completing a significant change assessment, the guidelines provided in the RAI Manual shall be followed.  This includes documenting "the initial identification of a significant change in terms of the resident's clinical status in the progress notes" as described in RAI page 2−7.

 

5)         Documentation used to support coding must be signed or initialed and dated.  Changes to documentation shall be done in accordance with professional standards of practice, which includes lining through the error, initialing and dating the changes made.

 

(Source:  Amended at 34 Ill. Reg. 3786, effective March 14, 2010)