Dietary4-13 - Iowa Dietetic Association

Report
Gwen Suntken RN BC, ICAC, MS
LTC Resources LLC
04/08/2013
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Disclaimer
 Information presented today is accurate as of
today
 It is your responsibility to stay current and
updated on changes
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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
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K100 Swallowing Disorder
Steps for Assessment
1. Ask resident if difficulty swallowing during 7 day
look back period
1.
Observe the resident during meals or at other times he
or she is eating, drinking or swallowing
2. Interview staff members of all shifts
3. Review medical record
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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
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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?
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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
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0.5 or more is nearest whole pound
0.4 or less is rounded down to nearest pound
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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
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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
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 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
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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
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K0510 Nutritional Approaches
 Check all that performed in last 7 days
1. While Not a resident
1. Only check column 1 if resident entered (admission
or reentry) in the last 7 days
2. If resident last entered more than 7 or more days
ago, leave column 1 blank
2. While a resident
1. Performed while a resident of the facility and within
the last 7 days
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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
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 Mechanically Altered Diet
 A diet specifically prepared to alter the texture or
consistency of food to facilitate oral intake


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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
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Sodium, potassium are examples
Low salt, diabetic, low cholesterol
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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
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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
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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
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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
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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
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K0700 Percent Intake by Artificial Route
Steps for assessment:
1. Review records to determine actual intake by
parenteral or tube feeding routes
2. 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
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K0700B Average Fluid Intake
IV or Tube Feeding in last 7 days
1. Review intake records
2. Add up total fluid received each day
3. Divide the week’s total intake by 7
4. Divide by 7 even if did not receive IV fluids or tube
feeding on each of the 7 days
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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, highprotein supplementation for wound healing
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 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
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Supplements should only be employed when nutritional
deficiencies are confirmed or suspected through a thorough
nutritional assessment (AMDA PU guidelines, page 6)
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 If determined warranted, tailor nutritional
supplementation to individual’s intake, degree of undernutrition, 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)
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Care Area Assessments
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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
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Facility to identify and use tools that are current or grounded
in current clinical standards of practice
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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
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MDS is Foundation
 MDS 3.0 has
 More details about personal preferences and choices
 Several improved screening tools

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BIMS, PHQ-9
Screening tools are not diagnostic
 Is starting point in assessment process
 Foundation for identifying possible issues/concerns
needing additional
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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
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Effective clinical problem solving
Effective decision making, including interventions
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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
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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
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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
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CAA Documentation
 The nature of the issue or condition - what is the
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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
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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
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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
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Questions
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LTC Resources
2445 120th St.
Meservey, Iowa 50457
641-358-6555
[email protected]
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