4/8/13
ADLs
acumen
The Foundation for Building insight
Healthcare
ideas
OAHCP Spring Conference attention
2013
reach
expertise
depth
agility
talent
Objectives
1.  Participant will be able to verbalize an
example of how ADLs affect Nursing Home
reimbursement.
2.  Participant will verbalize what the abbreviation
RUG stands for.
3.  Participant will know what an ADL aspect
means.
4.  Participant will understand the difference
between the definition of Limited Assistance
and Extensive Assistance.
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Definitions (Webster s & Medicine Net.com)
ü ADLs refer to a common, everyday tasks,
performance of which is required for personal
self-care & independent living.
ü Things we normally do in daily living including
any daily activity we perform for self-care such
as feeding ourselves, bathing, dressing and
grooming.
o  This ability or inability to perform these ADLs can
be used as a practical measure of ability /disability
Activities of Daily Living
In healthcare ADLs a term
used to refer to daily self-care
activities within an individual s
place of residence.
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ADL measurements are used
1.  Qualify for private insurance policies & or
programs
v
Often a trigger for benefits or payment options
2.  Federal legislation proposed for public
insurance plans to do the same.
3.  In some NH helps determine placement
within a facility
4.  May help categorize a disease process
National & International Surveys
Measuring the ability of elderly people to perform
their ADLs and how are they being conducted.
Do we get consistent estimates?
Recent studies suggest NO
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Studies
Studies from the early 1980s and 1990s.
Policy makers & insurance want to know:
1.  How many persons age 65 & older have ADL
problems?
2.  How many have ADL problems by each type
of activity?
How many elderly have more than
a threshold number of ADL problems?
Not all surveys use the same list of ADLs
Time Study (STRIVE)
ü CMS national NH time study used to establish
RUG IV model or PAYMENT
ü Began on-site data collection spring 2006
ü Finished in late summer 2007
ü Statistics came from 205 NH
ü 15 states, 12,000 residents
ü Evaluation of STRIVE date ultimately = PPS
RUG-IV model for payments (& many states
use case-mix payment systems for Medicaid
reimbursement.)
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Case Mix System
ü Medicare & Medicaid payment system consists
of 3 components:
1.  Staff time measures: Collected time from all
direct care staff
2.  Resident Assessments
3.  Cost calculations of resources
RUG
RUG =
Reimbursement
Utilization
Group
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RUG scores
ü ADL index required to qualify for RUG CMI
Example: Pneumonia & Fever
HE1 = $353.07/day (ADL=2-16)
CA1 = $208.81/day (ADL = 0-1)
Difference of: $144.26/day
Resident stays 14 days = $2,019.64
X 5 residents = $10,098.20
Mistake x 1 month = ?
Late loss ADLs
ü People retain their functional ability in these
4 areas the longest.
1.
2.
3.
4.
Bed mobility
Transfers
Eating
Toilet use
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Section G of the MDS 3.0
ü 11 ADLs in the assessment (MDS 3.0)
1.
2.
3.
4.
5.
6.
Bed Mobility
Transfers
Walk in room
Walk in corridor
Locomotion on unit
Locomotion off unit
7. Dressing
8. Eating
9. Toilet use
10. Personal hygiene
11. Bathing
ADLs MUST Be Right…..
1.  RUGs = Dollars
2.  Resident changes are identified – potential
Significant Changes
3.  Your Care is Rated
4.  Resident and Family Confidence
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Quality Measures and 5 Star Rating
Developed to help the consumer to understand
quality care in NH . A clinical performance
measure or efficiency of care
ü Quality Measures
ü 5 Star Rating - how your facility is ranked
v Res. showing significant declines quarter to
quarter?
ERRORS……..
1.  ADL documentation is completed – how?
2.  Document correctly – how?
3.  Why do we want our residents to be SO
good?
4.  Common mistakes?
5.  ADLs always important BUT when most
important?
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Reimbursement not the only advantage
ü Quality of Care
Example: Incontinent Residents should be on a
Check-and-Change Program .
>
>
This
mes
sag
e
has
bee
n
cros
s
post
ed
to
the
follo
win
g
Disc
ussi
ons:
MD
S
>
Con
nect
ion
and
LTC
Net
wor
k.
>
----------------------------------->
>
Hell
o,
>
>
Pati
ent
bein
g
adm
itted
with
acti
ve
HIV
AID
S
042
on
Med
A.
>
Wha
t if
any
addi
tion
al
codi
ng
is
req
uire
d to
insu
re
add
on
reim
bur
sem
ent.
>
Pati
ent
is
on
antr
etro
viral
sare
ther
e
any
dru
gs
or
any
circ
ums
tanc
es
>
whe
re
the
facil
ity
can
bill
for
thes
e
dru
gs
outs
ide
of
the
PPS
bun
dle?
>
>
Any
onli
ne
reso
urce
s
that
you
can
refe
r me
to?
>
>
Tha
nks
very
muc
h!
>
----------------------------------->
Gle
nda
Hyn
es
RN
>
Wes
tfiel
d
MA
>
----------------------------------->
>
4/8/13
Documentation – ADL Tracker
ADL
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
7a-3p
Transfers
/
/
/
/
/
/
/
3p-11p
Transfers
/
/
/
/
/
/
/
11p-7a
Transfers
/
/
/
/
/
/
/
7a-3p
Eating
/
/
/
/
/
/
/
3p-11p
Eating
/
/
/
/
/
/
/
11p-7a
Eating
/
/
/
/
/
/
/
7a-3p
Toileting
/
/
/
/
/
/
/
3p-11p
Toileting
/
/
/
/
/
/
/
11p-7a
Toileting
/
/
/
/
/
/
/
7a-3p
Bed Mob
/
/
/
/
/
/
/
3p-11p
Bed Mob
/
/
/
/
/
/
/
11p-7a
Bed Mob
/
/
/
/
/
/
/
etc
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Self Performance
Codes
ü 0= Independent: NO TALK, NO TOUCH
ü Staff does no assist, instruct, nor cue: resident
does
ü All activity ALONE no monitoring, no hands
on assistance. (with your eyes, you watched the
resident thru the door)
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ü 1=Supervised: TALK, NO TOUCH
ü Staff provides instructions or cueing (verbal),
but does not provide physical (hands on)
assistance.
ü Oversight and cueing staff uses mouth/voice
only.
ü NO HANDS
ü 2= Limited assistance: TALK and TOUCH
ü Staff talks to give instructions or cues and
touches resident to assist: can be as simple as
putting hands on resident s back or holding
his/her elbow while walking. Hands used for
more than set up, but does not lift any part of
the resident. The resident is highly involved,
you did some hands on assist but it was NONWEIGHT BEARING
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ü 3 = Extensive assistance: TALK, TOUCH, and
LIFT
ü Staff uses muscle power to lift, move, or shift
resident. This includes lifting legs into bed,
scooting buttocks into positioning in bed,
lifting arm to assist in self feeding. The resident
performed part of the activity, but
WEIGHTBEARING ASSIST (someone lifted
a part of the body) was required.
ü 4 = Total Dependence:
ALL ACTION BY STAFF
ü Resident dose not participate at all in any part
of the activity being done for him/her. The
resident didn t lift a finger to help
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ü  (7= the activity occurred only once or twice)
(not for CNA training)
ü 8 = the activity didn t occur during the entire
shift.
ü IF THE STAFF MEMBER HAS TOUCHED
THE RESIDENT AT ALL, CODE IS AT
LEAST LIMITED ASSIST.
Staff Performance
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ü 0 = No staff performance required, zip, zero,
nada.
ü 1= set up help only, maybe you undid a cover,
set the wheelchair at bedside or set out
grooming items
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ü 2= ONE person. Physically assisted by one
person
ü 3 = 2 or more physically assisted.
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ü 8= Activity didn t occur during the whole shift.
ADL Aspects or Components
Components of an ADL activity. These are
listed next to the activity in the item set on the
MDS. For example, the components of G0110H
(Eating) are eating, drinking, and intake of
nourishment or hydration by other means,
including tube feeding, total parenteral
nutrition and IV fluids for hydration.
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Components or Aspects of an ADL
Example: EATING
Eating
Drinking
Intake of Nourishment or Hydration by other
means:
v  Tube feeding
v  Parenteral nutrition
v  IV fluids for hydration
Components or Aspects of an ADL
Example: Bed Mobility
v Moving to & from a lying position
v Turns side to side
v Positions body while in bed or alternate sleep
furniture
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Components or Aspects of an ADL
Example Transfers
v How the resident moves between surfaces
v To or from:
1.
2.
3.
4.
Bed
Chair
Wheelchair
Standing position (excluding to/from bath or toilet)
Components or Aspects of an ADL
v Transfers on/off toilet (Toileting)
v Cleanses self after elimination
v Changes pad
v Manages ostomy or catheter
v Adjusts clothes
Do NOT include emptying bedpan, urinal
commode, catheter bag or ostomy bag
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Components or Aspects of an ADL
Example Toileting
v How resident uses the toilet
1.  Room
2.  Commode
3.  Bedpan
4.  Urinal
Toileting Scenario: Conflicting?
ü Performing an aspect or component of the
ADL activity for the resident is = extensive
assistance.
ü  Performing a portion of a component is not –
(CMS decided that zipping zippers, snapping
snaps, buttoning buttons is limited assistance,
not extensive assist because this is classified as a
portion or a PART of a component.)
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Scenario: 3 ways to get Ext Assist
1.  Provide weight-bearing assistance at least 3 Xs
2.  Perform the entire activity for the resident at
least 3 times
3.  Perform an entire component or aspect
of the activity for the resident at least 3
times
In the 7 day look-back period!
Toilet Use – Catheter or Ostomy?
Section G: Functional Status: (1)
Q: How do you code G0110I Toilet Use for
residents with a catheter or ostomy?
A: Be sure you are assessing both methods of
elimination….BOWEL AND BLADDER
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Catheter or Ostomy Care
Resident may require: (1)
ü only limited assist with catheter
but
ü extensive assist transferring on/off the toilet
ü Just emptying the catheter or ostomy bag does
not count,
ü but perineal /skin care does count
Teaching
ü Rule of Three
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Rule of Three
(*)
ü RAI Manual says: When an activity occurs
three times at any one given level THEN code
that level
ü When an activity occurs three times at multiple
levels THEN code the most dependent level
Example: Resident requires assistance at an
extensive level of assistance 3 times and at a
limited assistance 3 times then code it as
extensive assistance.
Activity occurs More than 1 level ?(*)
ü But Not Three Times at any ONE level
v Episodes of full staff performance are considered to
be weight bearing assistance when EVERY episode
is full staff performance=Total Dependence (4)
v When there are 3 or more episodes of a
combination of full staff performance & weightbearing assistance=Extensive Assistance (3)
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Rule of Three
ü Exceptions
1.  Total dependence: activity MUST require full
assistance EVERY TIME
2.  Activity did not occur: activity must NOT
have occurred at all or family and/or nonfacility staff provided care 100% of the time for
the activity over the entire 7-day period.
Rule of Three
Scenario: 3 ways to get Ext Assist
1.  Provide weight-bearing assistance at least 3 Xs
2.  Perform the entire activity for the resident at least
3 times
3.  Perform an entire component or
aspect of the activity for the
resident at least 3 times
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Teaching
(2)
ü What does each task or component of each
ADL mean .
TASK: Ask 5 different CNAs on different shifts
what the definition of toilet use means.
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Teaching
Task: Ask your CNAs or LPNs how would you
code toileting if you had to empty Mr M s urinal?
ü RAI Manual says: Do Not Include Emptying
of :
1.
2.
3.
4.
5.
Bedpan
Urinal
Bedside commode
Catheter bag
Ostomy
Teaching
ü Documentation Tools
Task: Ask 3 different CNAs what does it mean
for a resident to be in their 7 day look-back
period or window .
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Teaching
ü Documentation
Task: Tell a CNA or an LPN: I want you to
document the most dependent level so I can
use the Rule of Three .
Teaching- Are These Probing Questions?
ü How the resident uses the toilet room? Or
commode? Or bedpan? Or urinal?
ü How the resident transfers on/off the toilet
ü How the resident cleans themselves after
elimination
ü How the resident changes their pad
ü How the resident manages their ostomy or
catheter
ü How the resident adjusts their clothing before
elimination & after elimination
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Scenario: MEAL
Q: Resident completed all of his/her meal
independently except the last few bites the CNA
fed the resident. How should this ADL be coded
for this meal?
Scenario: MEAL
A: Extensive Assist of one person: 3/2
3 = Extensive Assistance
2 = one staff person was required to assist
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How would you code?
ü Example: a resident who can pull up their
pants but need assistance buttoning or zipping
their pants?
ü Example: a resident who might be able to
partially cleanse themselves but not fully cleanse
themselves?
How would you code?
Example: Resident uses a bedpan and when
the pan is placed by one CNA the resident
helps lift their hips onto the bedpan?
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How would you code?
Example: Mr. P. uses the bathroom but staff
assist Mr. P. to zip his pants, hand him a
washcloth, and remind him to wash his hands
after using the toilet daily. This occurred multiple
times each day during the 7-day look-back period.
How would you code?
Example: One staff person is cueing four
Dementia residents at a table to eat. They all start
out independently eating although cueing is
frequently needed with two (Resident A & B) and
occasionally with the other two (Residents C &
D). At one point the staff person uses hand over
hand to encourage Resident C to pick up the
fork, put food on the fork and put the fork into
their mouth.
What is the coding for: Resident A, B, C and D?
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Guided Maneuvering versus Weight-Bearing Assistance
ü How do we know?
ü Guided Maneuvering: if the resident can lift
the fork but staff assistance is just guiding the
resident s hand.
ü Weight-Bearing Assistance: if the staff member
supports some of the weight of the resident s
hand while helping the resident to move the
fork from the plate to the mouth=ext. assist.
How would you code?
ü Example: During bed mobility the staff person
hands the resident the trapeze bar so the
resident can reposition themselves in bed.
ü Example: During transfer from the bed to the
resident s recliner the CNA hands the resident
her walker.
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How would you code?
Example: The resident is from Islamabad. She is
in the last stage of her Dementia and is loosing
weight. Her daughter, Amina, is with her most of
the time. Amina prepares special meals for her
mom bringing it to her three times each day and
spending a great deal of time encouraging her
mom to eat for her. The resident does take small
quantities of the food some of the time.
How would you code this?
How would you code?
Example: Mr. T. is in a physically debilitated
state due to surgery. Two staff members must
physically lift and transfer him to a reclining chair
daily using a mechanical lift. Mr. T. is unable to
assist or participate in any way during the 7 day
look-back period.
How would you code?
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How would you code?
Example: Mrs. S required Supervision 5 times in
the look back period , while Limited Assistance
occurred twice, and Extensive Assistance & Total
Assistance each occurred twice.
Correct Code: G01101 would be
1 (Supervision) because there were not 3 or
more instances of a single higher level
May 2013 RAI update clarification
Think about that…..
Supervision?
In the Look Back Period you may find:
1.  Limited assist two times
2.  Extensive assist two times
3.  Total assist two times
BUT Supervision anything 3 or higher it would be
coded as SUPERVISION. This meets the Rule
of three.
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Responsibilities of ?
ü Monitor ALL ADL documentation to ensure
accuracy including:
v Asking probing questions to ensure components of
tasks were considered and the findings in the
documentation are identical to the documentation
v Look-back period – inaccuracies?
v Group education
v One to one education
Probing questions?
Examples:
MDS: How is Mrs. Cole doing since her stroke? Are
you having to dress her?
CNA: She is doing so well. She is back to her old self
again.
MDS: Wow! You re kidding. She just had her stroke
1 month ago.
CNA: I know but she has been trying so hard and has
done so well.
MDS: That s wonderful! Thank you!
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Probing Questions
ü Think about what probing questions should
sound like?
ü What are you trying to find out?
ü If you are having a difficult time communicating
with certain staff members, ask them to show
you.
Are your ADLs correct in your facility?
ü What do you need to initiate in your facility?
ü Do your staff understand components or
aspects ?
ü How do ADLs affect your facility?
ü What else?
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Questions???
Thank You!
Carol Smith, RN, BSN, RAC-CT
918-584-2900
csmith@bkd.com
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