For current RAI updates:

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For current RAI updates

• www.cms.hhs.gov/quality/mds2.0

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Top 5 Discrepant MDS Sections

• Section P - Special Treatments and
• Procedures
• 2. Section I - Disease Diagnosis
• 3. Section O - Medications
• 4. Section J Health Conditions
• 5. Section G Physical Functioning and
• Structural Problems

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Top 5 Discrepant Section G items

• G1b(A) - Transfers/Self-Performance
• G1a(A) - Bed Mobility/Self -Performance
• G1i(A) Toilet Use/Self-Performance
• G1d(A) Walk in Room/Self-Performance
• G1a(B) Bed Mobility/Support Provided

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Section G 1
Physical Functioning and Structural Problems
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G1(A) - ADL Self-Performance Codes

• 0. Independent
• 1. Supervision
• 2. Limited Assistance
• 3. Extensive Assistance
• 4. Total Dependence
• 8. Activity Did Not Occur During the
  Entire 7 Day Period

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Staff Support G1 (B) ADL Support Provided Codes

• 0. No Setup or Physical Help from Staff
• 1. Setup Help Only
• 2. One Person Physical Assist
• 3. Two Persons Physical Assist
• 8. ADL Activity Itself Did Not Occur During the
  Entire 7 Days

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Revised Long-Term Care Resident Assessment
Instrument Users Manual, Version 2.0(referred
to as RAI Users Manual)
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0. Independent - No help or staff oversight -OR-
Staff help/oversight provided only one or two
times during the last 7 days.
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• 1. Supervision - Oversight, encouragement, or
  cueing provided 3 or more times during last 7
  days -OR- Supervision (3 or more times) plus
  physical assistance provided, but only 1 or 2
  times during last 7 days.

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• 2. Limited Assistance - Resident highly involved
  in activity, received physical help in guided
  maneuvering of limbs or other non weight-bearing
  assistance on 3 or more occasions -OR- limited
  assistance (3 or more times), plus more
  weight-bearing support provided, but for only 1
  or 2 times during the last 7 days.

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• 3. Extensive Assistance - While the resident
  performed part of activity over last
• 7 days, help of following type(s) was provided 3
  or more times
• -- Weight-bearing support provided 3 or more
  times
• -- Full staff performance of activity (3 or more
  times) during part (but not all) of last 7 days.

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• 4. Total Dependence - Full staff performance of
  the activity during entire 7 day period. There is
  complete non-participation by the resident in all
  aspects of the ADL definition task. If staff
  performed an activity for the resident during the
  entire observation period, but the resident
  performed part of the activity himself/herself,
  it would not be coded as a 4 (Total
  Dependence).

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0.   No Setup or Physical Help from Staff
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• 1. Setup Help Only - The resident is provided
  with materials or devices necessary to perform
  the activity of daily living independently.

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2. One Person Physical Assist
3. Two Persons Physical Assist
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8. ADL Activity Did Not Occur During the Entire
7 Day Period -Over the last 7 days, the ADL
activity was not performed by the resident or
staff. The particular activity did not occur at
all.
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• Restorative Program Requirements
•         measurable objectives
•         interventions
•         evidence of periodic evaluation by a
• licensed nurse

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Refer to MDS RAI Users Manual

• Resident Assessment Protocol
• Activities of Daily Living Functional
• Rehabilitation Potential
• pages C 25- 29

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• Bed Mobility - How the resident moves to and from
  a lying position, turns side to side, and
  positions body while in bed, in a recliner, or
  other type of furniture the resident sleeps in,
  rather than a bed.

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• Transfer - How the resident moves between
  surfaces - i.e., to/from bed, chair, wheelchair,
  standing position. Exclude from this definition
  movement to/from bath or toilet, which is covered
  under Toilet Use and Bathing.

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• Walking in Room
• How the resident walks between location in
  his/her room.

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• Walk in corridor
• How the resident walks in corridor on unit

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• G8

ADL Functional Rehabilitation Potential
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• Locomotion on Unit - How the resident moves
  between locations in his or her room and adjacent
  corridor on the same floor. If the resident is
  in a wheelchair, locomotion is defined as
  self-sufficiency once in the chair.

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Scoring ADL Self Performance
Refer to the MDS RAI Users Manual Flow
chart on page 3-90
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• Locomotion Off Unit - How the resident moves to
  and returns from off unit locations (e.g., areas
  set aside for dining, activities, or treatments).
  If the facility has only one floor, locomotion
  off the unit is defined as how the resident moves
  to and from distant areas on the floor. If in a
  wheelchair, locomotion is defined as
  self-sufficiency once in chair.

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Nursing Rehabilitation/Restorative Care
Section P3
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• Dressing
• How the resident puts on, fastens and takes
  off all items of street clothing, including
  donning/removing prosthesis

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• G7
• Task Segmentation

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• Eating
• How the resident eats or drinks (regardless
• of skill). Includes intake of nourishment by
• other means (e.g., tube feeding, total
• parenteral nutrition)

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• Toilet Use - How the resident uses the toilet
• room, commode, bedpan, or urinal, transfers
• on/off toilet, cleanses, changes pad, manages
• ostomy or catheter, and adjusts clothes. Do
• not limit assessment to bathroom use only.
• Elimination occurs in many settings and
• includes transferring on/off the toilet,
• cleansing, changing pads, managing an
• ostomy or catheter, and clothing adjustment.

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The toileting activity subtask consist of

• Hands-on assist to adjust clothing
• Weight-bearing assist to lower her to the seat
• Cleaned self independently
• Stood up from toilet with assistive device
• Pulled pants up independently

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• Urinary catheter
• Incontinent briefs for bowel incontinence
• Check and change q2h and prn

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H3

• Appliances and Programs

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• Any Scheduled Toileting Plan
• Scheduled
• Toileting
• Program including organized, documented
  monitored and evaluated

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• Bladder Retraining Program
• Assessment
• Documented Plan of Care
• Communication to resident and care givers
• Scheduled times and approaches
• Evaluation of the plan
• Periodically reviewed and documented

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• Personal Hygiene - How the resident maintains
  personal hygiene, including combing hair,
  brushing teeth, shaving, applying makeup, and
  washing/drying face, hands, and perineum.

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Refer to the RAI Users Manual

• Section 1.12 Completion of the RAI
• Pages 1-17 thru 1-19

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• Participants in the assessment/process have
• the requisite knowledge to complete an
• accurate and comprehensive assessment
• conducted or coordinated by an RN who
• signs and certifies the completion of the
• assessment.
• The attending physician is an important
• participant in the process.

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• The assessment process
• identifies residents problems, needs, strengths,
  and risk factors

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Refer to the RAI Users Manual

• Section 1.12 Completion of the RAI
• pages 1-17 thru 1-18
• Section 1.13 Sources of Information for
  Completion of the MDS
• pages 1-18 thru 1-19

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Refer to the RAI Users Manual

• Section 1.14 CMS Clarification Regarding
  Documentation Requirements
• pages 1-23 thru 1-24

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• The process of information gathering
• should include
• Direct observation
• Communication with direct caregivers
• Consult all shifts
• Review relevant information in the residents
  clinical record
• Consult with family members with direct knowledge