Long-Term Care Survey Alert

Published on Fri Sep 26, 2008 PDF

Follow these tips and you will likely see a dip in your QI/QMs.

Incontinence can lead to negative outcomes, such as pressure ulcers and falls, not to mention serious survey citations. That's why you need a plan for identifying residents who can benefit from a toileting plan and documenting why you did or didn't provide it as part of the care plan process. And you need to know when you can code that toileting plan in Section H.

Start by identifying residents who flag on the quality indicator looking at the prevalence of occasionally or frequently incontinent residents without a toileting plan (H3a) or bladder retraining (H3b). Then look to see if those residents are candidates for a scheduled toileting plan either provided alone or as part of restorative nursing. For example, look to see if they are cognitively intact enough to participate and wish to do so, advises Nemcy Cavite Duran, RN, BSN, CRNAC, director of MDS for Dr. William O. Benenson Rehabilitation Pavilion in Flushing, NY.

Avoid this mistake: Don't automatically count certain residents out as candidates for a toileting plan. Elisa Bovee, MS, OTR/L, notes that a facility might have specific criteria to identify residents who are appropriate for a scheduled toileting plan, such as mobility status, cognitive status, and any type of bladder dysfunction leading to incontinence. But at some point, all residents should receive a trial of being put on the toilet, bedside commode or bedpan at an interval that fits their particular elimination pattern, advises Bovee, a consultant with Harmony Healthcare International in Topsfield, MA.

Real-world example: Surveyors expressed some concern that a certain facility had not put a resident requiring a Hoyer lift on a toileting plan, Duran recalls. As a result, the team is now careful to always ask residents requiring a lift if they want to be on a toileting program. If the person doesn't wish to participate, they carefully document that he refused despite teaching and continuing encouragement to participate. And they obtain the resident signature as part of the care plan, explains Duran. "In one case, occupational therapy worked with a resident so he could be lifted from bed directly onto the bedside commode safely."

Providing a toileting program is one thing -- coding it at H3a on the MDS is another. You have to evaluate whether a resident's toileting plan meets the RAI user's manual requirements for coding it as such. A recent Centers for Medicare & Medicaid Services' tip sheet for H3a says that a "generic, every two-hour toileting" plan or one that's the same for all incontinent residents won't count for coding that item.

According to the tip sheet, consider the following items when evaluating whether a scheduled toileting plan/program may be coded at H3a:

• The plan should contain an individualized, resident-specific toileting schedule that's listed either by hours or around the resident's pattern.

• 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.

• 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.

Also: 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.

Expert advice: If the resident is coded as totally incontinent, and the facility can't determine a pattern to the person's voiding, then continue to assist the person to use the toilet, bedpan or commode even though it may not meet the definition for H3a, suggests Evonne Fillinger, RN, BSN, WCC, RAC-CT, a consultant with Boyer & Associates. in Brookfield, WI.

On the other hand: If the facility completes an assessment that identifies a voiding pattern, the toileting plan is resident-specific -- and documentation shows the facility is maintaining or improving the resident's continence -- then you could code that in H3a, Fillinger advises. "The goal of a toileting program is typically to improve continence. If an assessment tool showed that on days one through five, the person had six incontinent episodes but after that, he had five," that documentation could show the person is making progress toward the goal, she says.

Quality improvement tip: To identify residents who are becoming more incontinent, the facility can develop its own internal quality indicator, notes Christie Teigland, PhD, director of health informatics and research for the New York Association of Homes & Services for the Aging.