PREVENTING AVOIDABLE DECLINE WITH RESTORATIVE NURSING

1. PREVENTING AVOIDABLE DECLINEWITH RESTORATIVE NURSING Presented by: Ruth West, RN, BS Director of Regulatory Compliance Healthcare Compliance Group Office: (516) 352-2037 Cell: (516) 477-1455 Email: ruthwest@optonline.net 1

2. Learning Objectives At the Conclusion of This Session the Participant Will: • Be Able to Define a Restorative Nursing Program • Be Able to Name the Components of a Restorative Nursing Program • Know the Restorative Nursing Activities to Promote and Maintain a Resident in Their Optimal Physical, Mental and Psychosocial Well-being (as per F309) to prevent decline 2

3. RESOURCES • CMS MDS 3.0 User’s Manual • http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html • CMS SNF PPS Information Resources • https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html?redirect=/SNFPPS/03_RUGIVEdu12.asp • CMS State Operations Manual • Appendix PP 3

4. Involved Regulatory Tags: • F246 F313 F385-F388 • F272 F314 F520-F521 • F278 F315 *F221 • F279-F283 F317-F318 *F406-F407 • F309 F319-F320 • F310 F323 • F311 F325-F327 • F312 F329 4

5. What is a Restorative Nursing Program? 1. A Restorative Nursing Program is an essential part of a resident’s overall plan of care to help ensure residents attain or maintain their optimal level of physical, mental and psychosocial well-being. (F309) 2. The goal of any Restorative Nursing Program is to enhance the resident’s quality of care and quality of life! 5

6. What is a Restorative Nursing Program? 3. The Program provides Nursing interventions that promote the Resident’s ability to adapt and adjust to living as independently and safely as possible. This is an important component of Restorative Nursing…… 4.Although a Restorative Nursing Program works in conjunction with Rehabilitation Therapy, the program is developed, implemented and evaluated by the Nursing department. It is an extension of the facility’s overall rehabilitation program. 6

7. What Does The RestorativeNursing Program Provide? • Focuses on what Resident’s can do • Promotes Resident’s abilities through the use of individualized, progressive programs…. • The program goals are centered around: • *creating independence • *improve self- image and self-esteem • *reducing level of care required by staff • Eliminates or minimizes degrading features of long-term care such as: restraints, incontinence and supervised feeding 7

8. What Restorative Nursing is Not! • Rehabilitation Restorative Therapy (PT/OT/Speech) • Competition with Rehabilitation Therapy • A Means to Increase Reimbursement Under Medicare and Medicare Case Mix • For Alert Resident Only • Not used to Ensure Good Survey Outcomes • The Restorative Nursing program restores and maintains functional ability to enhance Quality of Life and Quality of Care! 8

9. Restorative Nursing Program *“Program”-is defined as “a specific approach that is organized, planned, documented, monitored and evaluated.” MDS User’s Manual, Chapter 3-Section O *Utilizing recommendations from PT/OT/ST assessments and the comprehensive assessment, the Restorative Nursing Program recognizes each Resident's actual/potential rehabilitative needs, and institutes measures towards the prevention, restoration and maintenance of the Resident's physical and functional needs and abilities. 9

10. Benefits to the Resident • Improve Resident Functioning • Increase Resident’s Dignity and Self-esteem • Decrease Feelings of Depression • Increased Social Interactions • Enhance Quality of Life • Enhance Quality of care • Decrease Family Concerns and Complaints • PREVENT AVOIDABLE DECLINE!! (F309) 10

11. Benefits to the Facility • Decrease the Amount of Staff Involved in Direct Care Time • Increase Reimbursement Under the RUG IV and RUG III Medicare/Medicaid Payment Systems • Positive Impact on Quality Measures: • Incidence of decline in ADL function • Low-risk residents who lose control of their bladder/bowel function • Prevalence of occasional or frequent incontinence without a toileting plan 11

12. Restorative Care Criteria • Restorative Nursing involves Nursing interventions that assist or promote the Resident’s ability to attain his/her maximum functional potential. Rehabilitation or Restorative Care must meet all of the following additional criteria: 1. Resident Assessment of functional needs and strengths. • Measureable objectives and interventions must be documented in the care plan and in the clinical record. • Evidence of monthly evaluation by licensed nurse must be present in the clinical record. • CNA’s trained in the techniques that promote RESIDENT involvement in the activity. * This category does not include exercise groups with more than four (4) residents per trained caregiver. 12

13. Restorative Nursing Program Activities • RESTORATIVE NURSING CATEGORIES: 1. Range of Motion – Passive 2. Range of Motion – Active 3. Splint or Brace Assistance 4. Bed Mobility 5. Transfer 6. Walking/Ambulation 7. Bladder/Bowel Training 8. Dressing or Grooming 9. Eating or Swallowing 10. Amputation or Prosthesis Care • Communication *Other – any activity used to improve or maintain the resident’s self-performance in functioning. 13

14. RANGE OF MOTION ACTIVITIES • Range of Motion Exercises • Passive ROM (PROM) • Active ROM (AROM) • Active-Assist ROM (AAROM) • For Range of Motion (Passive): the caregiver moves the body part around a fixed point or joint through the Resident’s available range of motion. The Resident provides no assistance. • For Range of Motion (Active): any participation by the Resident in the ROM activity should be coded here. • For Range of Motion (AAROM) – Resident uses the muscles surrounding the joint to perform the exercise but requires some help from the caregiver(Active Assist) 14

15. RANGE OF MOTION ACTIVITIES • Range of Motion, Continued • PROM, AROM, AAROM activities performed simultaneously will count as one Restorative Nursing component on the MDS 3.0 • IF both active and passive range of motion exercises are performed as part of bathing or dressing ,or with ADL Care, this does notcount as part of a formal Restorative Nursing program. 15

16. SPLINT/BRACE ACTIVITIES • SPLINT OR BRACE ASSISTANCE – (2 TYPES): • 1.Staff provides verbal and physical guidance and direction that teachesthe resident how to apply, manipulateand carefor the brace/splint; • 2.Staff have ascheduled program of: • applying and removing a splint/brace, • observing the Resident’s skin and circulation under the device and correct position of the limb. **These activities ,again ,must be planned, scheduled and documented! 16

17. TRAINING AND SKILLS PRACTICE BED MOBILITY • Bed Mobility activity is used to improve or maintain the Resident’s self-performance in: • Moving to and from a lying position • Turning from side to side • Positioning self in bed WALKING/AMBULATION • Walking-activity to improve or maintain self-performance in walking with or without assistive devices. ..i e FAP WALKING/BED MOBILITY COUNT AS ONE SERVICE EVEN IF BOTH IS PROVIDED. 17

18. TRAINING AND SKILLS PRACTICE TRANSFER TRAINING • This activity is used to improve or maintain the Resident’s self-performance in moving between surfaces or planes either with or without assistive devices. 18

19. DRESSING/GROOMING ACTIVITY • Dressing/Grooming activity is used to improve or maintain the Resident’s self- performance in: • Dressing/undressing • Bathing and washing • Other personal hygiene tasks: • Shaving • Brushing Hair • Brushing Teeth • Applying makeup 19

20. EATING/SWALLOWING ACTIVITY • Eating or Swallowing-activity is used to improve or maintain self-performance in: • Feeding one’s self food and fluids • Activities used to improve or maintain Resident’s ability to ingest nutrition and hydration by mouth 20

21. COMMUNICATION ACTIVITY • Communication activity is used to improve or maintain Resident’s self-performance in: • Self-performance in newly acquired functional communication skills or • Assisting the Resident in using residual communication and adaptive services. 21

22. AMPUTATION/PROSTHESIS CARE • Amputation/Prosthesis Care-activity is used to to improve or maintain the Resident’s self-performance in putting on and removing a prosthesis, caring for the prosthesis, and providing appropriate hygiene at the site where the prosthesis attaches to the body • (e.g., leg stump or eye socket) Dentures are not considered in this coding 22

23. DELEGATION OF RESPONSIBILITIES • The Restorative Nursing Program is under the direction of the Nursing Director. It is coordinated and monitored by the Restorative Nursing Coordinator(s). • The Restorative Nurse Coordinator is responsible for the development, daily monitoring, implementation, communication, evaluation and resolution of problems, which may be encountered with each resident's Restorative Nursing Program. 23

24. RESTORATIVE NURSE COORDINATOR RESPONSIBILITIES • Direction, supervision, coordination and implementation of the Restorative Nursing Program. • Routine and ongoing staff education and inservice in the Restorative Care Process. • Monitoring to assure that all documentation systems are being completed per requirements and directions. • Routine quality assurance activities monitoring the proper implementation and effectiveness of the programs. • Identification and coordination of the purchase of needed equipment. • Consultation and liaison with physical therapy, occupational therapy, speech therapy and other adjunctive professionals with follow-up to appropriate staff. 24

25. RESTORATIVE NURSE COORDINATOR RESPONSIBILITIES • Screening and identification of individual resident's needs for restorative programming at admission, readmission and as needed for all residents. • Attending resident care plan meetings and assisting in the writing of individual care plans to identify specific problems, goals and restorative approaches. • Keeping the Policy and Procedure Manualcurrent and correct. • Instilling a restorative attitude to staff as well as keeping abreast of new interventions and trends in restorative care. • Individual observation and attention to the ever-changing needs of all of residents. 25

26. RESTORATIVE NURSE COORDINATOR QUALIFICATIONS • The Coordinator must be able to conduct and document Resident assessments under State Law. *In New York State only an RN is permitted to conduct assessment under the NYS Nurse Practice Act • The Coordinator must be a Licensed Nurse working under the direction of, and report directly to the Director of Nursing 26

27. WHERE DO I START TO DETERMINE WHO MAY BENEFIT FROM A RESTORATIVE NURSING PROGRAM TAKE A LOOK AT EACH RESIDENT • Determine if Resident has the potential to improve or maintain a function (Resident Assessment) • Does the Resident have the ability to learn? • Is mobility severely impaired? • Are there mood/behavior problems? • Is the Resident motivated? • Is the Resident being discharged from formal Rehabilitation Therapy??** 27

28. TRANSITIONING FROM REHABILITATION THERAPY TO RESTORATIVE NURSING PROGRAM • Residents who have met their restorative therapy goals may be a candidate for Restorative Nursing to maintain skills and function gained during the formal rehab program, communicate with PT/OT/ST • Residents at risk for decline in function following formal rehab treatment will benefit • Residents who are showing a decline in self-performance but are not candidates for a formal Restorative Rehabilitation Program 28

29. LOOK AT YOUR ROSTER MATRIX • Identify Residents who trigger on their last MDS 3.0 for: • Decline in ADL • Decline in functional ROM • Fall in past 30 days • Change in Bladder/Bowel Continence level • Indwelling catheter use and continued need • Bedfast Residents • Residents identified with swallowing problems • Residents with Language/Communication Problems 29

30. LOOK AT YOUR QI/QM REPORTS • Residents that Report Moderate to Sever Pain- Do they limit ROM or movement? • Fall with Major Injury • Lose Control of Their Bladder • Physically Restrained • Need for Help From Staff With Daily Activities has Increased • Residents Who Lose Too Much Weight • Residents with Signs of Depression 30

31. RESTORATIVE NURSING ASSESSMENT IT ALL STARTS WITH THE RESIDENT ASSESSMENT!! F279: §483.20(d) A Facility must.. use the results of the assessment to develop, review and revise the Resident’s comprehensive plan of care. Source: CMS State Operations Manual 31

32. RESTORATIVE NURSING ASSESSMENT In the delivery of a Restorative Care Program nothing is more essential than performing a basic task assessment. All basic self-care activities that are performed involve the completion of specific and predictable task, which require certain motor and cognitive skills…. Let’s Look At the Restorative Nursing Assessment (see attached) 32

33. RESTORATIVE NURSING ASSESSMENT • The Restorative Nursing Assessment Looks at the Resident’s Level of Self-Performance in the Following Areas: • Dressing • Grooming/Bathing • Eating • Toileting • Bed Mobility/Transfer • Locomotion • Splint/Brace/Prosthesis Care 33

34. RESTORATIVE NURSING ASSESSMENT When to Assess Residents: • All Residents should be assed for their restorative nursing needs and potential: • Upon Admission/Readmission • Upon Significant Change in Condition • Upon ANY Change in ADL Assistance Needs • On a Quarterly Basis, at a Minimum ( prior to quarterly MDS 3.0 schedule) • AT INITIATION/IMPLEMENTATION OF RESTORATIVE NURSING PROGRAM 34

35. RESTORATIVE NURSING ASSESSMENT Who May Assess a Resident? There are Three Parts of Assessment: 1. Task Completion 2. Functional Requirements on Unit; and 3. Assessment of Data Collected and Determination of Restorative Program Eligibility 35

36. RESTORATIVE NURSING ASSESSMENT • Task Completion Assessment: • Licensed Nurse Trained in Conducting the Task Completion Portion of the Resident Assessment Tool should be the assigned and responsible person • CNA Trained in Conducting the Task Completion Portion of the Resident Assessment Tool • Restorative Nurse Coordinator 36

37. RESTORATIVE NURSING ASSESSMENT • Functional Requirements on The Unit: • Licensed Nurse • Restorative Nurse Coordinator • Rehabilitation Staff • Remember the Assessment of Data Collected and Determination of Restorative Program Eligibility should be the…. • Licensed Nurse Permitted by State Law and Trained in Restorative Nursing Assessment Criteria, or • The Restorative Nurse Coordinator 37

38. REHABILITATION THERAPY ASSESSMENT • Rehabilitation Therapists (PT/OT/ST) should assess the Resident for functional status, limitations in function, contractures, restorative therapy potential and Restorative Nursing potential. Let’s Look At the Rehab Recommendation Form (see attached) 38

39. REHABILITATION THERAPY ASSESSMENT • All Residents will be screened by the Specialized Rehabilitation Therapists (PT/OT/ST) within 3-4 working days of admission, readmission or return from bedhold. • Thereafter, Residents will be rescreened by the Specialized Rehab Therapist on a quarterly basis, upon change in the Resident's condition or upon referral by the Attending Physician, Unit Nurse/Restorative Nurse Coordinator or other members of the Comprehensive Care team. 39

40. Step 2 Developing the Restorative Program • Upon Completion of the Restorative Nursing Assessment/Rehabilitation Recommendation; the Restorative Nurse Coordinator is Now Ready To Develop a Program……….. 40

41. RESTORATIVE NURSING PROGRAM REGULATORY COMPLIANCE MDS 3.0 CODING AND REIMBURSEMENT Part II MDS 3.0 State Operations Manual Reimbursement 41

42. LEARNING OBJECTIVES • This Session Will Concentrate On • Regulations Pertaining to the Care and Services Provided to Improve or Maintain a Resident’s Self-Care Performance • Proper Coding of the MDS 3.0, Section O – Restorative Nursing Program • How a Restorative Nursing Program Will Affect Reimbursement, Both Under Medicare Part A and Medicaid (For Case Mix States) 42

43. REGULATORY COMPLIANCE REGS Regulations Impact Every Aspect of Nursing Home Care. A Restorative Nursing Program is No Exception! Under the State Operations Manual, a decline in resident functioning is not permitted unless they are medically unavoidable. If the resident has a chronic disease or degenerative condition, the facility is expected to slow and delay the deterioration as much as possible. Documentation must support unavoidability of the decline and chronicle nursing actions to prevent or slow the decline….. 43

44. INVOLVED F TAGS • (F309) Facilities are required to provide necessary care and services to attain or maintain the highest practicable level of functioning in accordance with the assessment and care plan…. • F310 - Activities of Daily Living • F309 – Quality of Care • F311 – Restorative Program • F312 – Necessary Care and Treatment • F315 – Urinary Incontinence • F317 and F318 – Range of Motion 44

45. F310 - §483.25 Activities of Daily Living (a)(1) A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to - (i)  Bathe, dress, and groom; (ii)  Transfer and ambulate; (iii)  Toilet; (iv)  Eat; and (v)  Use speech, language, or other functional communication systems. 45

46. F311 & F312 - §483.25Restorative Programs to Maintain or Improve Abilities (2)A resident is given the appropriate treatment and services to maintain or improve his or her abilities (3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Intent §483.25(a)(2) 
The intent of this regulation is to stress that the facility is responsible for providing maintenance and restorative programs that will not only maintain, but improve, as indicated by the resident’s comprehensive assessment to achieve and maintain the highest practicable outcome. 46

47. F315 – §483.25(d) Urinary Incontinence • §483.25(d) (2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. • §483.25(d) (1) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary 47

48. F317 and F318 – Range of Motion • F317 §483.25(e)(1) A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; • F318 §483.25(e)(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion 48

49. AVOIDABLE vs. UNAVOIDABLE DECLINE IN FUNCTION An active, viable Restorative Nursing Program can maintain Resident’s highest practicable level of physical functioning thereby minimizing the risk of an unavoidable decline. A clinical condition may demonstrate that a reduction in abilities is unavoidable only if adequate assessment, appropriate care planning, and preventive care was provided, and resulted in decline of physical functioning. 49

50. AVOIDABLE vs. UNAVOIDABLE DECLINE IN FUNCTION Declines are avoidablewhen: • Assessment or interventions are inadequate • There is a lack of reassessment, care plan evaluation and care plan revision Declines are unavoidable when: • They are a consequence of the natural progression of the underlying disease • Risk assessments have been conducted on an on-going basis • Appropriate interventions have been developed and consistently implemented and have not altered the course 50