Dietary

1. Dietary Gwen Suntken RN BC, ICAC, MS LTC Resources LLC LTC Resources LLC 2013

2. Disclaimer • Information presented today is accurate as of today • It is your responsibility to stay current and updated on changes LTC Resources LLC 2013

3. MDS 3.0 • RAI Manual • Current version is October, 2012 • May be updates for dietary this fall • Intent of Section K: Swallowing/Nutritional Status • Assess conditions that affect resident’s ability to maintain adequate nutrition and hydration • Assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately LTC Resources LLC 2013

4. K100 Swallowing Disorder Steps for Assessment • Ask resident if difficulty swallowing during 7 day look back period • Observe the resident during meals or at other times he or she is eating, drinking or swallowing • Interview staff members of all shifts • Review medical record LTC Resources LLC 2013

5. K0100 Coding • A-Loss of liquids/solids from mouth when eating or drinking • B-Holding food in mouth/cheeks or residual food in mouth after meals • C-Coughing or choking during meals or when swallowing medications • D-Complaints of difficulty or pain with swallowing • Z-None of the above Do not code problem when interventions are successful in no symptoms during 7 day look-back period LTC Resources LLC 2013

6. K0100 • If items marked: • Are care plan interventions in place? • Even if not marked, but successful interventions in place, should be on the care plan • Is any further evaluation needed for problem? LTC Resources LLC 2013

7. K0200 Height and Weight • Height • Base height on admission • Subsequent assessment-should be at least yearly • Weight • Most recent measure in last 30 days • If taken more than once in 30 days, most recent weight • Weight rounding • 0.5 or more is nearest whole pound • 0.4 or less is rounded down to nearest pound LTC Resources LLC 2013

8. K0200 Weight Loss Steps for assessment • Compares weight in the 7 day look back period to weight at 2 snapshots in time • At point closest to 30 days preceding the current weight • At point closest to 180 days preceding the current weight Does not consider weight fluctuations outside of these two time points for MDS 3.0 coding However, should be continual monitoring LTC Resources LLC 2013

9. Definitions • Physician-Prescribed Weight Loss Regimen • A weight reduction plan ordered by the resident’s physician with the care plan goal of weight reduction • May employ a calorie-restricted diet or other weight loss diets and exercise • Also include planned diuresis • Weight loss must be intentional • Body Mass Index (BMI) • Number calculated from weight and height • Screening tool to identify possible problems LTC Resources LLC 2013

10. New Admission • Ask resident, family, or significant other about weight over past 30 and 180 days • Review medical records • Subsequent Assessments • Compare 7 day look back weight to 30 and 180 days and calculate if weight loss of 5 % in 30 days or 10% in 180 days Same with weight gain on K0310 LTC Resources LLC 2013

11. Weight Gain • Compares eight in the 7 day look back period to the closest 30 days and 180 days preceding the current weight • If resident gaining a significant amount of weight, do NOT wait for 30 or 180 day timeframe, should prompt a thorough assessment of resident’s nutiritional status LTC Resources LLC 2013

12. K0510 Nutritional Approaches • Check all that performed in last 7 days • While Not a resident • Only check column 1 if resident entered (admission or reentry) in the last 7 days • If resident last entered more than 7 or more days ago, leave column 1 blank • While a resident • Performed while a resident of the facility and within the last 7 days LTC Resources LLC 2013

13. Definitions All that apply in last 7 days • Parenteral/IV Feeding • Introduction of a nutritive substance into the body by means other than the intestinal tract • Feeding Tube • Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system LTC Resources LLC 2013

14. Mechanically Altered Diet • A diet specifically prepared to alter the texture or consistency of food to facilitate oral intake • Soft solids, pureed foods, ground meat • Should not automatically be considered a therapeutic diet • Does include altered fluids such as thickened liquids • Therapeutic Diet • Diet intervention ordered by health care practitioner as part of the treatment for a disease or clinical condition manifesting an altered nutritional status, to eliminate, decrease, or increase certain substances in the diet • Sodium, potassium are examples • Low salt, diabetic, low cholesterol LTC Resources LLC 2013

15. Coding tips for K0510A Parenteral/IV Feeding • When there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need • Supporting documentation should be noted in the resident’s medical record according to State and/or internal facility policy LTC Resources LLC 2013

16. Code: • IV fluids or hyperalimentation, including total parenteral nutrition (TPN) administered continuously or intermittently • IV fluids running at keep vein open • IV fluids contained in IV Piggybacks • Hypodermoclysis and subcutaneous ports in hydration therapy • IV fluids if needed to prevent dehydration if needed specifically for nutrition and hydration • Should be supporting documention LTC Resources LLC 2013

17. Items NOT be coded • IV Medications-coded in Section O • IV fluids to reconstitute and/or dilute medications for IV administration • IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay • IV fluids administered solely as flushes • Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis LTC Resources LLC 2013

18. Enteral feeding formulas • Should not be coded as a mechanically altered diet • Should only be coded as K0510D, Therapeutic diet when the formula is altered to manage problematic health condition, e.g. enteral formulas specific to diabetics LTC Resources LLC 2013

19. Coding Tips • Therapeutic diets not defined by content but why the diet is required • Must be specific nutritional requirement to remedy the alteration of nutritional status • Nutritional supplement • House supplement or packaged • Part of treatment for disease or condition does not constitute a therapeutic diet, but may be part of a diet • Supplements only coded here when administered as part of diet to manage problematic health conditions (e.g. for protein-calorie malnutrition) • Examples on K-12 and K-13 LTC Resources LLC 2013

20. K0700 Percent Intake by Artificial Route Steps for assessment: • Review records to determine actual intake by parenteral or tube feeding routes • Calculate proportion of total calories through these routes • If resident took no food or fluids by mouth or took just sips of fluid, step here and code 3, 51% or more • If more oral intake than this, consult dietician LTC Resources LLC 2013

21. K0700B Average Fluid Intake IV or Tube Feeding in last 7 days • Review intake records • Add up total fluid received each day • Divide the week’s total intake by 7 • Divide by 7 even if did not receive IV fluids or tube feeding on each of the 7 days LTC Resources LLC 2013

22. Section M Skin M1200D Nutrition or Hydration Intervention to Manage Skin Problems • Dietary measures received by the resident for the purpose of preventing to treating specific skin conditions, e.g., wheat free diet to prevent allergic dermatitis, high calorie diet with added supplementation to prevent skin breakdown, high-protein supplementation for wound healing LTC Resources LLC 2013

23. Intent • Determine whether or not one should receive nutritional or hydration interventions for skin problems based on individualized nutritional assessment • Review diet to determine if sufficient amounts of nutrients and fluids or already taking supplements that are fortified with US Recommended Daily Intake of nutrients • Supplements should only be employed when nutritional deficiencies are confirmed or suspected through a thorough nutritional assessment (AMDA PU guidelines, page 6) LTC Resources LLC 2013

24. If determined warranted, tailor nutritional supplementation to individual’s intake, degree of under-nutrition, and relative impact of nutrition as a factor overall; and obtain dietary consultation as needed (AMDA PU Therapy Companion, page 4). • Additional supplementation is not automatically required for pressure ulcer management • Any interventions should be specifically tailor to the resident’s needs, condition, and prognosis (AMDA PU Therapy Companion, page 11) LTC Resources LLC 2013

25. Care Area Assessments LTC Resources LLC 2013

26. Care Area Assessments • Are triggered responses to items coded on the MDS • Specific to a resident’s possible problems, needs or strengths • Provides additional information for development of an individualized care plan • CMS does not mandate any specific tool • Facility to identify and use tools that are current or grounded in current clinical standards of practice LTC Resources LLC 2013

27. CAA’s • Not required for Medicare PPS only assessments • Only for OBRA comprehensive assessments • Admission • Annual • Significant Change • Significant Correction of a prior Comprehensive • When OBRA comprehensive and PSS combined are required LTC Resources LLC 2013

28. MDS is Foundation • MDS 3.0 has • More details about personal preferences and choices • Several improved screening tools • BIMS, PHQ-9 • Screening tools are not diagnostic • Is starting point in assessment process • Foundation for identifying possible issues/concerns needing additional LTC Resources LLC 2013

29. MDS as screening tool • If certain responses on the MDS • THEN Care Area Assessments triggered • BECAUSE item may be associated with possible presence of a condition, concern, risk or problem • Further assessment needed to determine significance • Because MDS findings alone cannot guide • Effective clinical problem solving • Effective decision making, including interventions LTC Resources LLC 2013

30. CAA should help staff: • Consider resident as a whole, unique with strengths • Identify areas of concern that may warrant interventions • Develop interventions to help improve, stabilize, or prevent decline • Address the need and desire for other important considerations such as advanced care planning and palliative care LTC Resources LLC 2013

31. Conducting the Assessment Step 1: Identify the trigger • Usually a sign, symptom, or other indicator of possible problem, need, or strength Step 2 : Identify the triggered Care Area LTC Resources LLC 2013

32. Conducting the Assessment Step 3 : Conduct thorough assessment of the entire Care Area • Include factors that could cause or contribute to the symptom • Include factors for which the symptom places the resident at risk • Some factors will be on the MDS, many will not LTC Resources LLC 2013

33. CAA Documentation • The nature of the issue or condition - what is the problem for this resident? • Causes and contributing factors • Complications affecting or caused by the care area for this resident • Risk factors that arise because of the presence of the condition • Factors that must be considered in developing individualized care plan interventions • Need for referrals to other health professionals LTC Resources LLC 2013

34. CAA Documentation • Written documentation of the CAA findings and decision-making process may appear anywhere in resident’s record • No particular location or format is required • Section V indicates Location and Date of CAA documentation r/t decision-making LTC Resources LLC 2013

35. Federal requirements • F 272 Nutritional Status • Nutritional status refers to weight, height, hematologic and biochemical assessments, clinical observation of nutrition, nutritional intake, resident’s eating habits and preferences, dietary restrictions, supplements, and use of appliances LTC Resources LLC 2013

36. Questions LTC Resources 2445 120th St. Meservey, Iowa 50457 641-358-6555 bgs@frontiernet.net LTC Resources LLC 2013