MDS Alert

Compare your answers to these scenarios against CMS clarifications.

Which of the following could you code as "any scheduled toileting plan" at H3a?

Example No. 1: Mr. M., who has a diagnosis of congestive heart failure and a history of left-sided hemiplegia from a previous stroke, has had an increase in urinary incontinence. The team has assessed him for a reversible cause of the incontinence and has evaluated his voiding pattern using a voiding assessment. After completing this assessment, a plan was developed that called for toileting every hour for four hours after receiving his diuretic, then every three hours until bedtime. The team has communicated this approach to the resident and the care team and has placed these interventions in the care plan. The team will re-evaluate the resident's response to the plan after one month and adjust as needed.

Example No. 2: Mrs. H. has a diagnosis of advanced Alzheimer's disease. She depends on the staff for her ADLs, does not have the cognitive ability to void in the toilet or other appropriate receptacle, and is totally incontinent. Her voiding assessment indicates no pattern to her incontinence. Her care plan states that due to her total incontinence, staff should follow the facility standard policy for incontinence, which is to check and change every two hours while awake and apply a super-absorbent brief at bedtime so as not to disturb her sleep.

Select one of the following:

1. Both of the above examples count as a scheduled toileting plan because they include interventions based on an assessment.

2. Only example No. 1 counts as a scheduled toileting plan.

Answer: Option 2. Code the first example as a scheduled toileting plan but not the second example.

According to a Centers for Medicare & Medicaid Services May 2008 MDS tip sheet, "the definition of item H3a asks you to indicate whether the resident is on a plan for bowel and/or bladder elimination whereby staff members, at scheduled times each day, either take the resident to the toilet room, give the resident a urinal, or remind the resident to go to the toilet during the 14-day observation period. This item includes bowel habit training and/or prompted voiding.

Clarifications: There are three key concepts to consider when coding item H3a:

Scheduled --" means performing the activity according to a specific, routine time that has clearly been communicated to the resident (as appropriate) and to caregivers.

Toileting --" means voiding in a bathroom, commode or other appropriate receptacle (e.g., urinal, bedpan).

Plan/Program --" means a specific approach that is organized, planned, documented, monitored and evaluated. All three (3) key components must be present in order to code H3a.

CODING TIPS: Simply providing incontinence care for a resident does not mean that the resident is on a toileting plan. The plan must be based on the individualized assessment of the resident's need for a toileting program. Consider the following items when evaluating whether a scheduled toileting plan/program may be coded at H3a:

1. The plan should contain an individualized, resident-specific toileting schedule -- listed either by hours or around the resident's pattern. [Note: This does not include generic, every two-hour toileting; nor does it include a plan/schedule that is the same for all incontinent residents.]

2. The resident's individualized plan should be clearly communicated and be available and accessible to staff and the resident (as appropriate), via the resident care plan, flow records, verbal and written report, etc.

3. The resident's response to the toileting program and subsequent evaluation should be documented in the clinical record and include when changes have been made, depending on the resident's response.

4. If the resident is coded a '4' (totally incontinent) in item H1, then clinical documentation would need to be present to support the appropriateness of coding item H3a."

Editor's note: Download the MDS tip sheet excerpted above at http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20ToiletingTipSheet.pdf.