MDS Alert

Here's how to provide a restorative program that you can code on the MDS.

The motto for restorative nursing ought to be "provide and code." 
 
If you don't provide restorative care, surveyors could claim the facility isn't doing everything possible to prevent residents' functional decline or pressure ulcers.
 
"The truth is, you aren't doing everything you can if you don't provide restorative nursing," says Gene Larrabee, a consultant and principal of Primus Care Inc. in Valparaiso, IN.
 
And if you provide but don't code restorative, the SNF's Medicare residents won't RUG into low rehab even though they receive the required number of rehab therapy minutes. Restorative also drives Medicaid case-mix in some states.

Know the Requirements
 
Yet even though your nursing interventions walk and talk like restorative, you can't code them as such unless they meet the criteria spelled out the by the Resident Assessment Instrument user's manual.
 
"The restorative services must be well documented and part of a restorative care plan with measurable goals and interventions," says Gary Woessner, principal of Woessner Healthcare Consulting in Edina, MN (for examples of measurable restorative goals, see "Stumped on Writing Restorative Goals?, this issue).
 
The clinical record must also "show evidence" that a licensed nurse is providing "periodic supervision" of the program. Nursing assistants must be trained in the techniques that promote "resident involvement" in the activity as well, according to the RAI manual.
 
"The CNAs providing restorative interventions are trained through their initial certification process and are usually evaluated and retrained through continuing education," relates Marilyn Mines, RN, a consultant with FR&R Healthcare Consulting in Deerfield, IL.

Count the Minutes
 
To code one day of restorative services in Section P3a-k, staff has to provide 15 minutes of that restorative service within a 24-hour period (for a rundown of the services in this section, see "Know What Counts Before You Code Section P3a-k", this issue).
 
To qualify for Medicare low rehab, the resident must receive two restorative activities (15 minutes each) coded in Section P3 daily for six days of the seven-day lookback. The minutes don't have to be consecutive over the 24-hour period, however, Woessner notes. For example, the CNAs might ambulate the patient 10 minutes on the day shift and five minutes in the evening for a total of 15 minutes for the day.
 
You can count a toileting or bladder/bowel retraining program coded in Section H as one of the two restorative programs. But a toileting program counts only if it's organized, planned and part of a plan of care with goals.
 
Facilities don't have to count minutes to code a toileting or bladder retraining program in Section H (with a 14-day lookback), notes B.J. Collard, BSN, GNP, CPHQ, Principal of CTS Inc. in Westminster, CO. But facilities should be consistent, Collard advises. "If they document minutes for their other restorative programs, they should document minutes spent toileting a resident," she suggests. "Of course, if the facility is documenting a resident's toileting program each shift, staff is certainly spending 15 minutes a day assisting the resident," she concedes.
 
Remember: Under Medicare, certain combinations of restorative services count as one program; e.g., bed mobility and walking, and active and passive range of motion. And you can only count a toileting program or a bladder retraining program as one restorative service.

Develop Tracking Formats  

Restorative minutes can slip through the cracks if staff don't document them consistently. Try using a restorative flow sheet where staff records minutes of care right after they perform them, Woessner suggests. "Or give CNAs small notepads to keep in their scrub pockets to jot down what restorative activities they've done with each resident and then record them at the end of the shift," he advises. "If the charge nurse knows the restorative plan for each resident, he or she can check to make sure it was done and documented."
 
CNAs at Loch Haven Nursing Facility in Macon, MO, capture restorative nursing minutes using a hand-held personal digital assistant that acts as a stopwatch. The PDAs then upload and flow the minutes automatically to the MDS database. (For more information, see the January 2004 MDS Alert, p.6.)

Get Everyone With the Program
 
Some facilities don't want to provide the restorative care for the required minutes six times a week, notes Pauline Watts, PT, a co-founder of Encompass Education Inc., a rehabilitation consulting firm in Palm Harbor, FL. But a facility can make all of its CNAs part of the restorative program. "That way, if the CNA ambulates the resident to the bathroom as part of the restorative plan of care and the nursing care plan, you can count that toward the minutes of restorative," Watts points out.
 
Activities staff trained in restorative techniques (and supervised by nursing) can provide some creative and fun restorative services that count in Section P3. For example, cooking groups could count as restorative for a resident who needs to prepare light meals and snacks as a goal for discharge or transfer to assisted living - or to improve his functioning in the nursing facility, advises Cheryl Field, MS, RN, director of clinical and reimbursement services for LTCQ Inc. in Lexington, MA.
 
Tip: Check your state practice act before using activities staff to provide restorative programs. "Some states forbid anyone but CNAs to provide hands-on restorative services, such as  range of motion," Mines notes. Also, you can't code exercise groups with more than four residents per supervising caregiver.