Section 147.TABLE A Staff Time (in Minutes) and Allocation by Need Level

a) Effective July 1, 2003, each Medicare and Medicaid certified nursing facility shall complete, and transmit quarterly to the Department, a full Minimum Data Set (MDS) for each resident who resides in a certified bed, regardless of payment source. A description of the MDS items referenced in the tables found following subsection (e) of this Table A are contained in the Long Term Care Resident Assessment Instrument User's Manual available from the Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 (December 2002).

b) Table A identifies MDS items that shall be used to calculate a profile on each Medicaid-eligible resident within each facility.

c) The profile for each Medicaid-eligible resident shall then be blended to determine the nursing component of the nursing facility's Medicaid rate.

d) Each MDS item in Table A includes a description of the item and the variable time referred to in Section 147.150(c)(1). The variable time assigned to each level represents the type of staff that should be delivering the service (unlicensed, licensed, social worker and activity) and the number of minutes allotted to that service item.

e) Following is a listing of the reimbursable MDS items found in Table A.

1) Base Social Work and Activity

2) Activities of Daily Living (ADL)

3) Restorative Programs

PROM/AROM

Splint/Brace

Bed Mobility

Mobility/Transfer

Walking

Dressing/Grooming

Eating

Prosthetic Care

Communication

Other Restorative

Scheduled Toileting

4) Medical Services

Continence Care

Catheter Care

Bladder Retraining

Pressure Ulcer Prevention

Moderate Skin Care Services

Intensive Skin Care Services

Ostomy Care

IV Therapy

Injections

Oxygen Therapy

Chemotherapy

Dialysis

Blood Glucose Monitoring

End Stage Care

Infectious Disease

Acute Medical Conditions

Pain Management

Discharge Planning

Nutrition

Hydration

5) Mental Health (MH) Services

Psychosocial Adaptation

Psychotropic Medication Monitoring

Psychiatric Services (Section S)

Skills Training

Close or Constant Observation

6) Dementia Services

Cognitive Impairment/Memory Assistance

Dementia Care Unit

7) Exceptional Care Services

Extensive Respiratory Services

Total Weaning From Ventilator

Morbid Obesity

Complex Wound Care

Traumatic Brain Injury (TBI)

8) Special Patient Need Factors:

Communication: add 1% of staff time accrued for ADLs through Exceptional Care Services

Vision Problems: add 2% of staff time accrued for ADLs through Exceptional Care Services

Accident/Fall Prevention: add 3% of staff time accrued for ADLs through Exceptional Care Services

Restraint Free Care: add 2% of staff time accrued for ADLs through Exceptional Care Services

Activities: add 2% of staff time accrued for ADLs through Exceptional Care Services

MDS ITEMS AND ASSOCIATED STAFF TIMES

Throughout Table A, where multiple levels are identified, only the highest level shall be scored.

1) Base Social Work and Activity

Level		Unlicensed	Licensed	Social Worker	Activity
I	All Clients	0	0	5	10

2) Activities of Daily Living

Documentation shall support the following for scoring Activities of Daily Living.

1) Coding of Section G, Physical Functioning, and Structural Problems on the MDS during the look-back period.

2) MDS coded level of resident self-performance and support has been met.

3) When there is a widespread lack of supporting documentation as described in subsections (1) and (2) of this item (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.

Level	Composite Scores	Unlicensed	Licensed	Social Worker	Activity
I	Composite 7-8	50	7.5 RN 7.5 LPN
II	Composite 9-11	62	9.5 RN 9.5 LPN
III	Composite 12-14	69	10.5 RN 10.5 LPN
IV	Composite 15-29	85	12.5 RN 12.5 LPN

ADL Scoring Chart for the above Composite Levels

MDS values equal to "-" denote missing data.

ADL	MDS items	Description	Score
Bed Mobility	G1aA = - or G1aA = 0 or G1aA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1aA = 2.	Self-Performance = limited assistance	3

	G1aA = 3 or G1aA = 4 or G1aA = 8 AND G1aB = - or G1aB = 0 or G1aB = 1 or G1aB = 2.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur Support = missing Support = no set up or physical help Support = set up help only Support = 1 person assist	4

	G1aB = 3 or G1aB = 8.	Support = 2+ person physical assist Support = activity did not occur	5

Transfer	G1bA = - or G1bA = 0 or G1bA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1bA = 2.	Self-Performance = limited assistance	3

	G1bA = 3 or G1bA = 4 or G1bA = 8 AND G1bB = - or G1bB = 0 or G1bB = 1 or G1bB = 2.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur Support = missing Support = no set up or physical help Support = set up help only Support = 1 person assist	4

	G1bB = 3 or G1bB = 8.	Support = 2+ person physical assist Support = activity did not occur	5

Locomotion	G1eA = - or G1eA = 0 or G1eA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1eA = 2.	Self-Performance = limited assistance	3

	G1eA = 3 or G1eA = 4 or G1eA = 8 AND G1eB = - or G1eB = 0 or G1eB = 1 or G1eB = 2.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur Support = missing Support = no set up or physical help Support = set up help only Support = 1 person assist	4

	G1eB = 3 or G1eB = 8.	Support = 2+ person physical assist Support = activity did not occur	5

Toilet	G1iA = - or G1iA = 0 or G1iA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1iA = 2.	Self-Performance = limited assistance	3

	G1iA = 3 or G1iA = 4 or G1iA = 8 AND G1iB = - or G1iB = 0 or G1iB = 1 or G1iB = 2.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur Support = missing Support = no set up or physical help Support = set up help only Support = 1 person assist	4

	G1iB = 3 or G1iB = 8.	Support = 2+ person physical assist Support = activity did not occur	5

Dressing	G1gA = - or G1gA = 0 or G1gA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1gA = 2.	Self-Performance = limited assistance	2

	G1gA = 3 or G1gA = 4 or G1gA = 8.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur	3

Hygiene	G1jA = - or G1jA = 0 or G1jA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1jA = 2.	Self-Performance = limited assistance	2

	G1jA = 3 or G1jA = 4 or G1jA = 8.	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur	3

Eating	G1hA = - or G1hA = 0 or G1hA = 1.	Self-Performance = missing Self-Performance = independent Self-Performance = supervision	1

	G1hA = 2.	Self-Performance = limited assistance	2

	G1hA = 3 or G1hA = 4 or G1hA = 8	Self-Performance = extensive assistance Self-Performance = total dependence Self-Performance = activity did not occur	3
	Or
	K5a = 1 or K5b = 1 and Intake = 1	Parenteral/IV in last 7 days Tube feeding in last 7 days See below
	Where Intake = 1 if
	K6a = 3 or	Parenteral/enteral intake 51-75% of total calories
	K6a = 4	Parenteral/enteral intake 76-100% of total calories
	Or Intake = 1 if
	K6a = 2 and	Parenteral/enteral intake 26-50% of total calories
	K6b = 2 or	Average fluid intake by IV or tube is 501-1000 cc/day
	K6b = 3 or	Average fluid intake by IV or tube is 1001-1500 cc/day
	K6b = 4 or	Average fluid intake by IV or tube is 1501-2000 cc/day
	K6b = 5.	Average fluid intake by IV or tube is 2001 or more cc/day

3) Restorative Programs

With the exception of amputation/prosthesis care and splint or brace assistance restoratives, the total number of restorative programs eligible for reimbursement shall be limited to four, with no more than three being a Level II restorative. Scheduled toileting shall be included in this limit. Splint or brace assistance and amputation/prosthesis care shall be reimbursed independently. A resident coded in I1t (CVA/stroke), I1v (hemiplegia/hemiparesis), I1w (Multiple Sclerosis), I1x (paraplegia) or I1cc (Traumatic Brain Injury) on the MDS and also coded as B4£2 (cognitive skills for decision making) shall be limited to a total of six restoratives with no more than four being a Level II restorative. A Department designed assessment shall be required quarterly to assess the resident's endurance and the resident's ability to benefit from two or more restorative programs.

For the following restorative programs: bed mobility, mobility/transfer, walking, dressing/grooming, and eating, when the corresponding ADL is coded a "1" under self-performance on the current MDS, the previous MDS must have a code of greater than "1" to qualify for reimbursement.

If PROM is scored, AROM is reset to zero unless the resident has a diagnosis of CVA, hemiplegia/hemiparesis, multiple sclerosis, paraplegia or traumatic brain injury.

When the number of restoratives coded on the MDS exceeds the allowable limits for reimbursement, the following order shall be used.

A) Eating Restorative

B) Scheduled Toileting

C) Walking Restorative

D) Transfer Restorative

E) PROM/AROM

F) Bed Mobility Restorative

G) Communication Restorative

H) Dressing/Grooming Restorative

I) Other Restorative

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 should 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 program defined 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 in the RAI Manual for the individual restoratives.

Passive Range of Motion (PROM)

The following documentation shall support the following for scoring 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.

Lev	MDS items	Description	Unl	Lic	SW	Act
	G4aA > 0 or	Any function limits in ROM of neck
	G4bA > 0 or	Any function limits in ROM of arm
	G4cA > 0 or	Any function limits in ROM of hand
	G4dA > 0 or	Any function limits in ROM of leg
	G4eA > 0 or	Any function limits in ROM of foot
	G4fA > 0 or	Any function limits in ROM of other limitation or loss
	G4aB > 0 or	Any function limits in voluntary movement of neck
	G4bB > 0 or	Any function limits in voluntary movement of arm
	G4cB > 0 or	Any function limits in voluntary movement of hand
	G4dB > 0 or	Any function limits in voluntary movement of leg
	G4eB > 0 or	Any function limits in voluntary movement of foot
	G4fB > 0	Any function limits in voluntary movement of other limitation or loss
	AND
I	3 ≤ P3a ≤ 5	3 to 5 days of PROM rehab	10	3 RN 3 LPN
II	6 ≤ P3a ≤ 7	6 to 7 days of PROM rehab	15	3 RN 3 LPN

Active Range of Motion (AROM)

The following documentation shall support the following for scoring 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.

Lev	MDS items	Description	Unl	Lic	SW	Act
	G4aA > 0 or	Any function limits in ROM of neck
	G4bA > 0 or	Any function limits in ROM of arm
	G4cA > 0 or	Any function limits in ROM of hand
	G4dA > 0 or	Any function limits in ROM of leg
	G4eA > 0 or	Any function limits in ROM of foot
	G4fA > 0 or	Any function limits in ROM of other limitation or loss
	G4aB > 0 or	Any function limits in voluntary movement of neck
	G4bB > 0 or	Any function limits in voluntary movement of arm
	G4cB > 0 or	Any function limits in voluntary movement of hand
	G4dB > 0 or	Any function limits in voluntary movement of leg
	G4eB > 0 or	Any function limits in voluntary movement of foot
	G4fB > 0	Any function limits in voluntary movement of other limitation or loss
	AND
I	3 ≤ P3b ≤ 5	3 to 5 days of AROM rehab	8	2 RN 2 LPN
II	6 ≤ P3b ≤ 7	6 to 7 days of AROM rehab	12	2 RN 2 LPN

Splint/Brace Assistance