SECTION J HEALTH CONDITIONS April 22, 2014 1-3PM

1. SECTION JHEALTH CONDITIONS April 22, 2014 1-3PM Pain - Dyspnea Tobacco Use Prognosis Problem Conditions Falls

2. Objectives • Understand the intent is to document health conditions that impact a resident’s functional status and quality of life • Understand how to code Section J correctly • Understand how to conduct the Pain Interview • Understand what needs to be on the care plan so staff knows how to provide care regarding the health conditions and to keep the resident safe

3. J0100A, B, C PAIN MANAGEMENT • 5 day look-back period • Review medical record • MAR, Care Plan, Progress Notes, PT, OT • Interview staff • Pain management interventions - medication and non-medication • Pain medication regimen - medication given to relieve or prevent reoccurrence of pain, not medication that primarily targets treatment of underlying condition - See Physician Order (J-1)

4. A. Scheduled Pain Medication Regimen • Order defines dose & specific time intervals for administration • Code 1. Yes. Medical record contains documentationthat scheduled medication received. (J-2)

5. B. Received PRN Pain Medication • Order specifies dose & indicates given on as needed basis, including time interval, i.e. every four hour as needed for pain. • Code 1. Yes. Medical record contains documentation that PRN medication either received OR offered but declined OR was offered and declined (J-2)

6. C. Non-Medication Pain Intervention Scheduled and implemented non-pharmacological interventions include, but not limited to: bio-feedback, application of heat/cold massage, physical therapy, nerve block, stretching and strengthening exercises, chiropractic, electrical stimulation, radiotherapy, ultrasound, acupuncture. Herbal medications not included. (J-3)

7. C. Received Non-Med Pain Intervention • Code 1. Yes. Medical record contains documentation non-medication pain intervention scheduled as part of care plan and documentedintervention actually received and assessed for efficacy (J-3)

8. Scenario – Code J0100A, B, C Mrs. Nowantpain had the following pain management program in the past 5 days: • Hydrocodone/acetaminophen ordered and received 5/500 1 tab (po) every 6 hours. Discontinued on day 1 of look-back period. • Acetaminophen 500mg (po) every 4 hours. Ordered on day 2 of look-back period. • Cold pack to left shoulder applied by PT BID. PT notes that resident reports significant pain improvement after cold pack applied. How would you code A., B., C.? A. Yes. Hydrocodone; B. No C. Yes. Cold Pack

9. J0200: Should Pain Assessment Interview Be Conducted? • If Comatose (B0100), SKIP to J1100: Shortness of Breath • Review: • Is resident rarely or never understood? (B0700) • Does resident want or need interpreter? (A1100) • Is interpreter available? • Code 0. No. Interview should not be attempted • If resident rarely/never understood, or needs or wants interpreter but one not available • SKIP to J0800: Indicators of Pain or Possible Pain • Code 1. Yes. Interview should be conducted • If resident understood, interpreter not needed or is available

10. Items J0300 - J0600Presence, Frequency, Effect on Function, Intensity • Conduct interview day before ARD or on ARD to capture pain episodes during look back period • Introduce interview topic and purpose • Ask each item in order provided • May use other terms for pain or interview techniques if unsure or hesitant in answer • Prompt to think about most recent pain to help determine if occurred within look-back period • Go to next question if chooses not to answer

11. J0300 - J0600 - Interview • Introduction before interview • Suggested language: “I’d like to ask you some questions about pain. The reason I am asking these questions is to understand how often you have pain, how severe it is, and how pain affects your daily activities. This will help us to develop the best plan of care to help manage your pain.”

12. J0300: Pain PresenceHave you had pain or hurting anytime in the last 5 days? • Code 0. No pain. Even if due to having received pain management interventions • If Code 0, interview complete. • SKIP to J1100: Shortness of Breath • Code 9. Unable to answer. Unable to answer, does not respond, or gives nonsensical response. • SKIP to J0800: Indicators of Pain or Possible Pain item

13. J0400: Pain FrequencyHow much of the time have you experienced pain or hurting? • Code most frequent response, if difficulty selecting between two responses • Do not give definition of responses. • 1. Almost constantly; 2. Frequently • 3. Occasionally; 4. Rarely • Code 9. Unable to Answer. Unable to respond, does not respond, or gives nonsensical answer. Still continue to J0500, J0600, J0700.

14. J0500: Pain Effect on Function A. Sleep at Night B. Day to Day Activities • Coding Definitions same for A. & B. • Code 1. Yes. Pain interfered with: • A. Sleep; B. Daily Activities • Code 9. Unable to answer. Does not respond, or gave nonsensical response.

15. J0600: Pain Intensity • Choice of two Rating Scales: • Numeric (J0600A) • Verbal Descriptor (J0600B) • Use same Scale as on prior assessment, if possible • May show and tell written response options at same time • Resident may respond verbally, pointing to written response, or both • Leave code response box of scale not used “blank”

16. J0600: Pain Intensity • A. Numeric Rating Scale (00 - 10) • Zero (00) = No pain  Ten (10) = Worst Pain Possible • Record response as two digit number • B. Verbal Descriptor • 1. Mild; 2. Moderate; 3. Severe; 4. Very, severe, horrible; 9. Unable to answer

17. Interviewing Vulnerable Elders Search for Video on Interviewing Vulnerable Elders Click on Video Interviewing Vulnerable Elders – You tube I encourage you to watch this if you haven’t. Pain

18. J0700: Should Staff Assessment for Pain be Conducted? • Code 0. No. Answered J0400: Pain frequency • 1. almost constantly or • 2. frequently or • 3. occasionally or • 4. rarely • SKIP to J1100: SOB • Code 1. Yes. J0400 coded 9. Unable to answer

19. J0800: Indicators of Pain or Possible Pain in Last 5 Days • Review Medical Record • Interview Staff • Observe during ADLs and Treatments • Do not code behavioral symptoms here. • If code Z.  SKIP to J1100. SOB

20. J0800. Indicators of Pain or Possible Pain – Coding • A. Non-verbal sounds • (whining, gasping, moaning of groaning) • B. Vocal complaints of pain (that hurts, ouch, stop) • C. Facial expressions • (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) • D. Protective body movements or postures • (bracing, guarding, rubbing, massaging a body part/area, clutching or holding a body part during movement) • E. None of above observed or documented, SKIP to J1100. SOB

21. J0800: Indicators of Pain or Possible Pain - Scenario Mrs. W. has been unable to verbally communicate following a massive cerebrovascular accident (CVA) several months ago and has a Stage 3 pressure ulcer. There is no documentation of pain in her medical record. The CNA who cares for her reports that she does not seem to have any pain. You observe the resident during her pressure ulcer dressing change. During the treatment, you observe groaning and a wrinkled forehead What would you check for J0800? A. Non-verbal sounds C. Facial Expression

22. J0850: Frequency of Indicator of Pain of Possible Pain in Last 5 Days • Complained of pain or showed evidence of pain during look-back period. • Number of days • Not number of times per day • Code 1. 1-2 days • Code 2. 3-4 days • Code 3. Daily

23. J1100: Shortness of Breath (Dyspnea) • Distressing, decreased interaction, activity, & QOL • Potential indication of change in condition • Interview resident, staff, family • Review medical record • Observe occurrence with activity or avoidance of activity to prevent occurrence • A. with exertion; B. sitting at rest; C. when lying flat 7 day look back

24. J1300: Current Tobacco Use • Negative effects • shorten life expectancy • create health problems that interfere with daily activities • adversely affect quality of life. • Code any form of tobacco us(not e-cigs) 7 day look back

25. J1400: PrognosisHas condition or chronic disease that may result in a life expectancy < 6 months? • Terminally ill – individual has medical prognosis of life expectancy of 6 months or less if illness runs normal course • Code 1.Yes. Physician documentation in clinical record: • Resident Terminally Ill OR receiving Hospice Services.

26. J1550: Problem Conditions • C. Internal Bleeding • bright red • occult • tarry stools • gross • hematuria • hemoptysis • Severe nosebleed 7 day look back • A. Fever- Obtain Baseline Temperature prior to look back period 2.4 degrees F > Baseline or T.100.4 on Admission • D. Dehydration- 2 of 3 Criteria B. Vomiting • <1500 ml of fluid daily • 1 or more clinical signs of dehydration (J-26) • Fluid loss > Fluid intake

27. J1700-J1900: Definition of Fall J-27 • Unintentional change in position coming to rest on ground, floor, or onto next lower surface, (e.g. onto bed, chair, or beside mat). • May be witnessed, reported by resident or observer or identified when resident found on floor or ground. • Include any fall whether it occurred at home, while in community, in acute hospital or in nursing home. • Falls not result of overwhelming external force (e.g. resident pushes another resident. • Intercepted fall occurs when resident would have fallen if had not caught self or had not been intercepted by another person – still considered fall.

28. J1700A, B, C: Fall History on Admission/Entry or Reentry regardless of location • Complete if: • Admission assessment (A0310A=01) OR • First assessment (OBRA or Scheduled PPS) since most recent admission/entry, or reentry (A0310E=01) • Information gathered: • Resident, Family, Significant Other Interview • Transfer form and other records • Fracture R/T Fall • Documented bone fracture in problem list from medical record, x-ray report, or by history from resident or caregiver that occurred as direct result of fall or recognized and later attributed to fall. Not fracture from trauma of car crash or pedestrian accidents (J-28)

29. J1700: Fall History onAdmission/Entry or Reentry A1600. Entry Date • A. Fall in prior month (0-1 month) • B. Fall in prior 2-6 months • C. Fracture R/T fall in prior 0-180 days

30. J1800: Any Falls since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is most recent • Look Back Period • Since Admission/Entry or Reentry • Entry Date (A1600) to ARD of Assessment • Since Prior Assessment • Day after ARD of previous assessment through ARD of current assessment • All falls any location • Code 0. No.  SKIP to K0100: Swallowing Disorder

31. J1900: Definitions of Injury Severity related to Falls – J-31 • Injury related to fall: Any documented injury that occurred as direct result of, or recognized within short period of time (e.g. hours to few days) after fall and attributed to fall. • Severity Levels • A. No injury • B. Injury, except major: Includes skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes resident to complain of pain • C. Major injury: Includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma

32. J1900: Number of Fallssince Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) -whichever is more recent- • Same look back period as J1800 • Fall log • Number of Falls at each Severity Level • Code each fall only once • If multiple injuries occurred in single fall, code for highest level of injury

33. Care Plan Considerations • Pain management is very important. Staff needs to know what is causing the pain, where it is, and how the elder indicates pain. Many negative behaviors are a result of pain. Oral pain is #1 in LTC. • Include non-pharmacological interventions, i.e. changing position, walking, warmth, etc. • Include what pain medication is ordered.

34. Care Plan Considerations continued • Shortness of breath; Is oxygen used? If so, how many liters, use of mask or nasal cannula, when it is to be used, storage of equipment when not in use, how often equipment is changed When sitting what needs to be done? Use oxygen, encourage deep breathing, stress free environment When in bed – elevate head of bed how high, use oxygen, never lie flat

35. Care Plan Considerations continued • Do they use tobacco? If they do, was education provided about a cessation program? If they agree to stop what is in place to support them If they decline, what is being done to ensure they use the tobacco safely

36. Care Plan Considerations continued • The physician has documented they have a life expectancy of less than 6 months; Find out the elder’s preferences for goals and interventions of care. Talk to them and/or their family. When Hospice is involved, you must incorporate their care plan with yours. The Hospice staff is part of the care plan team.

37. Care Plan Considerations continued • Falls – staff needs to know how to prevent falls. Interventions need to be started on admission using their diagnosis and fall history. • A new fall intervention must be added to the care plan immediately after each fall. Hint; do not use “educate the elder to use their call light to get assistance to get up” if they have dementia.