Transcription

MDS-ALS Training ManualTraining Manual for the Minimum Data Set Assisted Living Services AssessmentTool MDS-ALSRevised byThe Maine Department of Health and Human ServicesOffice of MaineCare ServicesApril 2008This document builds on the work of John N. Morris and Katharine Murphy of the HebrewRehabilitation Center for the Aged (HRCA) in Boston and Sue Nonemaker, of the Health CareFinance Administration (now the Center for Medicare and Medicaid Services) in developing atraining manual for the Nursing Home Resident Assessment Instrument and with Catherine Hawes,Charles Phillips, Brant Fries, and Vince Mor on the development of the original RAI trainingmanual.Revised April 2008

MDS-ALS Training ManualTABLE OF CONTENTS1.THE ASSISTED LIVING AND LEVEL III RESIDENTIAL CARE ENVIRONMENT .61.1.Background and Overview .61.2.Facility Responsibilities for Completing MDS Assessments .61.3.Assessor Responsibilities .101.4.Schedule of Assessments .102.CONFIDENTIALITY REQUIREMENTS AND RESIDENTS’ RIGHTS .112.1.3.The Importance of Maintaining Confidentiality .11GENERAL PROCEDURES FOR COMPLETING THE INSTRUMENTS.123.1.Completing the Assessments .12Client Records . 12Client, Family and Staff Interviews . 123.2.Probing .123.3.Recording Responses to Items .133.4.Instrument and Recording Conventions .14Mandatory Response Selection . 143.5.Sources of Information for the Assessment.15The Client's Record . 15Direct Care Staff. 15The Client . 15The Client's Family . 154.3.6.Order To Follow in Completing the MDS-ALS .163.7.The MDS-ALS Is Not A Questionnaire .163.8.Overview To The Item-by Item Guide to MDS-ALS .16FACE SHEET : BACKGROUND INFORMATION .17Section AA. Identification Information .17AA1.AA2.AA3.AA4.AA5.AA6.AA7.Client Name . 17Gender . 18Birth Date . 18Race/Ethnicity . 18Social Security and Medicare Numbers . 18Facility Name and Provider Numbers. 18MaineCare (formerly Medicaid) Number (if applicable) . 19Section AB. Demographic Information .19AB1. Date of Entry . 19AB2. Admitted From (At Entry) . 19AB3. Lived Alone (Prior to Entry) . 20Revised April 20081

MDS-ALS Training ManualAB4. Zip Code of Prior Primary Residence . 21AB5. Residential History 5 Years Prior to Entry . 22AB6. Lifetime Occupation . 23AB7. Education (Highest Level Completed). 23AB8. Primary Language . 24AB9. Mental Health History. 24AB10. Conditions Related to MR/DD Status (Mental Retardation/ Developmental Disabilities)25AB11. Alzheimer/Dementia History . 25Section AC. Customary Routine .26AC1. Customary Routine . 26Section AD. Face Sheet Signatures .30AD1. Signature(s) of Person(s) Completing Face Sheet . 30AD2. Date Completed . 305.FUNCTIONAL ASSESSMENT .31Section A. Identification And Background Information .31A1.A2.A3.A4.A5.A6.A7.A8.A9.A10.Client Name . 31Social Security and Medicare Numbers . 31Facility Name and Provider Numbers. 31MaineCare (formerly Medicaid) Number . 32Assessment Date . 32Reason for Assessment . 32Marital Status . 33Current Payment Source(s) for Stay . 33Responsibility/Legal Guardian . 34Advanced Directives . 36Section B. Cognitive Patterns .37B1.B2.B3.B4.Memory . 38Memory/Recall Ability . 39Cognitive Skills for Daily Decision-Making . 40Cognitive Status . 41Section C. Communication/Hearing Patterns .41C1.C2.C3.C4.C5.Hearing. 42Communication Devices/Techniques . 42Making Self Understood . 43Ability to Understand Others . 44Communication . 44Section D. Vision Patterns.45D1.D2.Vision . 45Visual Appliances . 46Section E. Mood and Behavior Patterns .46E1.E2.Indicators of Depression, Anxiety, Sad Mood . 47Mood Persistence . 49Revised April 20082

MDS-ALS Training ManualE3.E4.E5.E6.E7.E8.Mood . 49Behavioral Symptoms . 49Suicidal Ideation or Suicide Attempts . 53Sleep Problems. 53Insight into Mental Health . 54Behaviors . 54Section F. Psychosocial Well-Being .54F1.F2.F3.Sense of Initiative/Involvement . 54Unsettled Relationships . 55Life Events History . 57Section G. Physical Functioning .57G1.G1.G2.G3A.G3B.G3C.G4.G5A.G5B.G6.G7.G8.(A) Activities of Daily Living (ADL) Self-Performance . 58(B) ADL Support Provided . 67Bathing . 68Modes of Locomotion . 69Main Mode of Locomotion . 70Bedfast/Chairfast. 70Self Performance in ADLs . 70IADL Self Performance . 70Transportation . 73ADL and IADL Functional Rehabilitation or Improvement Potential (7-day look back) 74New Devices Needed . 76Self Performance in IADLs . 76Section H. Continence in Last 14 Days .77H1.H2.H3.H4.H5.Continence Self-Control Categories . 77Bowel Elimination Pattern . 78Appliances and Programs . 79Use of Incontinence Supplies. 80Change in Urinary Continence. 80Section I. Diagnoses .81I1.I2.Diagnoses . 81Other Current Diagnoses. 85Section J. Health Conditions .85J1.J2.J3.J4.J5.J6.J7.J8.Problem Conditions . 85Extrapyramidal Signs and Symptoms . 87Pain Symptoms . 88Pain Site . 89Pain Interferes . 90Pain Management. 91Accidents. 91Danger of Fall . 92Section K. Oral/Nutritional Status .92K1.K2.Oral Problems . 92Height and Weight . 93Revised April 20083

MDS-ALS Training ManualK3.K4.Weight Change. 93Nutritional Problems or Approaches . 94Section L. Oral/Dental Status.95L1.Oral Status and Disease Prevention . 95Section M. Skin Condition .96M1.M2.M3.Skin Problems . 96Ulcers – due to any cause. 96Foot Problems and Care . 97Section N. Activity Pursuit Patterns .97N1.N2.N3.N4.N5.N6.N7.N8.N9.Time Awake . 98Average Time Involved in Activities . 98Preferred Activity Settings . 99General Activity Preferences (Adapted to client's current abilities). 99Preferred Activity Size . 100Preferences in Daily Routine . 100Interaction With Family and Friends . 101Voting . 101Social Activities . 101Section O. Medications .102O1.O2.O3.O4.O5.O6.O7.O8.Number of Medications . 102New Medications . 102Injections . 103Days Received the Following Medication . 103Self-administered medications . 104Medication preparation and administration . 104Medication Compliance . 104Misuse of Medication . 105Section P. Special Treatment and Procedures cial Treatments, Procedures, and Programs . 105Intervention Program for Mood, Behavior, Cognitive Loss . 108Need for Ongoing Monitoring . 110Rehabilitation/restorative care . 110Skill Training . 111Adherence With Treatments/Therapies/Programs . 111General Hospital Stays . 111Emergency Room (ER) Visit(s) . 112Physician Visits . 113Physician Orders . 113Abnormal Lab Values . 114Psychiatric Hospital Stay(s) . 114Outpatient Surgery . 114Section Q. Service Planning .114Q1.Q2.Client Goals . 114Conflict . 115Revised April 20084

MDS-ALS Training ManualSection R. Discharge Potential .115R1.Discharge Potential . 115Section S. Assessment Information .116S1.S2.S3.Participation in Assessment . 116Signatures. 116Case Mix Group . 116Section T. Preventive Health Behaviors .116T1.Preventive Health . 116Section U. Medications List.117U1.6.Medications . 117DISCHARGE TRACKING FORM .117D1. Identification Information .1171.2.3.4.5.6.7.Resident Name . 117Gender . 118Birth Date . 118Race/Ethnicity . 118Social Security and Medicare Numbers . 118Facility Name and Provider Numbers. 119MaineCare (formerly Medicaid) Number (if applicable) . 119D2. Demographic Information .1191.2.Date of Entry . 119Admitted From (At Entry) . 119D3. Assessment/Discharge Information .1201.2.3.7.Discharge Status. 120Discharge Date . 122Signature(s) of Person(s) Completing the Assessment . 122EDITING COMPLETED INSTRUMENTS .1227.1.Form Edits .1227.2.Electronic Edits .123Revised April 20085

MDS-ALS Training Manual1. THE ASSISTED LIVING AND LEVEL IIIRESIDENTIAL CARE ENVIRONMENT1. THE ASSISTED LIVING AND LEVEL III RESIDENTIAL CARE ENVIRONMENT1.1. Background and OverviewIn light of the growing demand for long-term care and the significance of the assistedhousing sector, there is a need for greater understanding of the types of clients being served, thequality of care they receive and the ability to adequately reimburse providers for the care andservices required to meet these needs. In Maine, the Minimum Data Set for Assisted Living Services(MDS-ALS) has been developed to assist providers in the care and service planning process. TheMDS-ALS consists of a core set of screening and assessment elements, including commondefinitions and coding categories that form a basis for a comprehensive assessment. The MDS doesnot provide all information a facility will need for a comprehensive assessment. Facilities will wantto augment and add items to this core set as appropriate to complete their assessment process.Additional items relevant to the client’s status should be documented in their record.Information from the MDS-ALS assessment also is used to reimburse providers for care andservices provided to MaineCare (Maine’s SCHIP and Medicaid program) members residing in thesesettings. As of July 2004 providers of housing with assisted living programs and Adult Family CareHomes, now referred to as Level III Residential Care Facilities (RCF-III) are required to collect andsubmit MDS-ALS information on all clients for use in quality monitoring and reimbursement.Maine has a long history of development and use of the family of assessment tools known asthe Resident Assessment Instrument (RAI) Minimum Data Set (MDS). Since the early 1990s Mainehas used the RAI in nursing facilities for assessment, care planning, quality of care andreimbursement. Maine developed a tool, referred to as the MED form, to determine eligibility forlong term care services. This tool was based on the MDS. In 1995, Maine implemented the MDSfor Residential Care facilities (MDS-RCA). The MDS-RCA is currently used in Level IVResidential Care facilities. The MDS-ALS is similar to the MDS-RCA; however it does not includethe Resident Tracking nor the Correction Forms.The intent of this manual is to offer guidance, instruction and example for the effective useand completion of the MDS-ALS. The manual should be readily available for staff use andconsultation as they complete the assessment process. Assessing staff should be trained in the useof the MDS-ALS prior to its use. The Maine Department of Health and Human Services routinelyoffers training sessions on how to complete the MDS assessment. Contact the MDS Helpdesk formore information at 207-287-1830.1.2.Facility Responsibilities for Completing MDS AssessmentsThis section outlines a facility’s responsibility to complete the MDS assessment undervarious operational situations. At the end of this section a table is included summarizing thefacility’s responsibility in each situation. Not all types of long term care facilities are required tocomplete MDS assessment forms to comply with licensing regulations or MaineCare payment. Youmust consult with the Maine Department of Health and Human Services, Division of Licensing andRegulatory Services (DLRS) (1-800-791-4080) to understand your responsibilities related toRevised April 20086

MDS-ALS Train

I, II and III. Provider Relations staff are available to address policies, procedures and any claims issues that you may have. If you have any questions concerning MaineCare policies, please contact Provider Relati