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Healthcare Training Institute - Quality Education since 1979

Section 16
Documentation Compliance

Table of Contents | NCCAP/NCTRC CE Booklet

This Course gives you the basic starter phrase, or root, for the Goal or Approach.  Your corporate policy, computer software package, state regulations, and CMS surveyor interpretation all combine to determine how specific of a numeric qualifier is needed.  For example in the case of a Goal, you might want or need to add to the samples given in this Manual the follow numerical qualifiers.
a length of time like “for 10 seconds”
a ratio like “4 out of 5 times”
a distance like “2 feet”
a percentage like “25% of the time”
a size like a “two inch hole”
a number of objects like “three caps”
Remember, especially if you are new to your position, your Corporate Consultant or Care Plan/MDS Coordinator is usually your best source regarding documentation compliance specifics.  For easy reference purposes in this Manual, sample Goals and Approaches have been boxed in, and are also listed in Appendix B at the end of this Manual.

No Problems Given
As you will note in this Series, I do not give you sample Care Plan Problems to address because one Success Therapy® Care Plan Goal could be used with a limitless number of problems.  For example, in the case of Caps-in-the-Bowl, this activity may address the cognitive and physical problems of “only able to understand simple directions;” “disoriented to time, place and person;” “stiff fingers movement;” and so on.  But, if a problem is not currently listed on the Care Plan that seems to be addressed by a Success Therapy® activity, consider adding the problem to that resident’s Care Plan.  Consult corporate policy for the specific procedure regarding adding Problems to residents’ Care Plans.  As you know, all entries must flow from, be compatible with, and support the information on the MDS assessment. 
 
Care Plan Goal Revision
The following is a sample goal progression or Difficulty Scale.  After “to do...” write the name of the activity
Goals: to do...with total physical assistance... (numerical qualifier) 
Goals: to do... independently...  (numerical qualifier)
Goals: to do... with partial physical assistance (explain assistance given)... (numerical qualifier)
Goals: to do... with an elbow prompt...  (numerical qualifier) 
Goals: to do... after 4 demonstrations...  (numerical  qualifier)
Goals: to do... after 1 demonstration...  (numerical qualifier) 
Goals: to do... independently once started...  (numerical qualifier)

At the end of your Goal, add a numerical qualifier listed in paragraph one of this Section.  A sample Goal would read,

 Be sure to discuss this goal-writing formula with your Corporate Consultant prior to using it.

Using ST® to Delete Quality Indicator (QI) Flags
As you may know your Quality Indicator percentage is based upon the number of residents you code on the MDS in Item N2 as a 2 or a 3.  MDS item N2 rates the amount of time your resident is involved in activities.  Coding a 2 or 3 indicates involvement in activities less than 1/3 of the time.  When your facility is compared to other facilities in your geographic area and providing a similar level of care, your facility is ranked.  Therefore the number of residents coded a 2 or a 3 in Item N2 that flag the Activity QI will vary from facility to facility depending on the rankings computed by your Department of Health. 

For example, in some facilities in Florida if over 80% of the residents are coded a 2 or a 3 for MDS Item N2, the Activity QI would be flagged.  However, for some facilities in Michigan, 75% is the flagging percentage.  The significance of a flag is that at survey time the surveyors are told to focus more attention on flagged areas and to examine the quality of care for those residents more in depth.

Often times residents that are involved less than 1/3 of the time are low functioning residents. Thus the seven Success Therapy® activities in this Course provide you with not only specific ideas to increase resident involvement, but a specific method to keep them involved, via the ST® Activity Project Bags and In-service Training Sheets.  (Important Note:  The MDS is always undergoing revisions, as is the criteria and system  for writing deficiencies.  So if the above QI/MDS system no longer applies to your facility, consider the preceding an interesting history lesson.  Your Corporate Consultant or MDS/Care Plan coordinator will have the most current information regarding the status of Quality Indicators, the MDS, as they relate to CMS Survey Deficiencies.)