Realize the Benefits of Restorative Nursing
Contents
1. RESTORATIVE NURSING TRANSFER AND DOCUMENTATION FORM Transfer PROBLEM Unable to hold feeding utensils in hands amp feed self due to severe arthritis in both hands GOAL Resident will be able to use built up spoon fork amp knife to eat 50 of each meal by 4 7 04 PROGRAM APPROACHES Restorative dining to provide skill practice for resident to feed herself Hand utensils to resident Replace fork amp spoon in her right hand amp knife in her left when she drops utensils CNA to place hands firmly over residents hands and guide her when her hands quiver or shake Daffy Duck OT 4 1 04 VISIT 4 2 04 Repeated instruction amp return demonstration on how to firmly hold and guide the hands when they are quivering or shaking Daffy Duck OT F U VISIT 4 5 04 The CNA is following the program and providing the instructions appropriately Resident ate 50 of her noon meal with her utensils 4 5 04 Daffy Duck OT Demonstration Instruction 4 1 04 DD Return Demonstration 1 4 04 GH Master List 1 4 04 MB Care Plan Update 4 1 04 MB Flow Record 4 1 04 MB CNA Assignment 4 1 04 MB DD Daffy Duck OT GH Glenda Harvey RCNA MB Melon Ball RN Unit Manager Progress Note Admission 4 1 04 Resident was unable to feed herself because she could not grasp regular feeding utensils due to arthritic pain and joint changes She was fitted with built up utensils and worked with OT for 2 weeks and transferred today to the Res2. Date Review Completed Reviewer Signature Title Guidelines and Definitions Functional limitation is the key in scoring Section G4 Functional Limitation in Range of Motion Limitation in ROM as defined in the MDS User s Manual is limitation that interferes with daily functioning particularly with activities of daily living or places the resident s at risk for injury CTS Inc Nurse Consultants and Educators 303 426 9712 www restorativenursing com Copyright 2002 BJ Collard CTS Inc QUALITY INDICATOR FACILITY SYSTEM LEVEL REVIEW When resident level review identifies areas needing improvement apply the QI process to the related system Domain Quality Indicator Percentage IMPROVEMENT AREAS Check the boxes that apply based on the resident level review and define the improvement areas Consider the entire sample and the severity of one or more cases Pattern of inaccurate MDS coding L Pattern of care issues deficient practice Could this be an immediate jeopardy situation Before answering review the worksheet on the attached page Yes 2 If yes proceed with questions Was the facility aware of this situation Yes No If aware when and how If not aware should they have been II INVESTIGATION WHY WHAT IS THE ROOT CAUSE III ACTION PLAN Reviewer Signature Title Date IV FOLLOW UP Reviewer Signat
3. 10 Realize the Benefits of Restorative Nursing ExHiBIT Roles Level amp III CNAs LEVEL II Stabilize the program before transfer to Level 111 Work with challenging residents indefinitely Perform therapy delegated tasks LEVEL Maintenance How Do You Organize an Individual Resident Program Staff need to know who is on a program and program specifics program structure Master list CAN assignment sheet Communication systems Care plan Staff need to document the program program structure Flow sheets Narrative note designated area 20 Realize the Benefits of Restorative Nursing 11 ExHiBIT 12 How Do You Organize an Individual Resident Program Staff need to know vulnerable times when residents are at risk for ADL decline program structure Admission no therapy nursing assessment therapy screening Resident non program performance reporting protocol Program transitions transfer procedure Acute problem development nursing assessment Hospice end of life nursing assessment 21 How Do You Organize a Facility Program Staff need to take ownership organization structure Philosophy Committee or task force staff involvement restorative culture Staff motivation resident motivation e Staff need to know their role and how to perform Restorative techniques an
4. Staff support Supervision Cues Demonstration person Resident eats of meal Devices Built up Spoon Fork Knife Rocker Spoon Fork Knife Plate guard Non skid device under plate Sippe Deep dish plate Problem Need Strength a Potential for improvement in eating skills Needs intervention to maintain eating skills a Related to Cognition impaired mental deficit Behavior problem Sequence problem Diagnosis Alzheimer s Disease CVA Dementia Fractured hip left right Physical limitations Amputation Grasp poor holding rail walker etc Motor skills impaired Fine Gross Pain Paralysis Rt Left ROM limited Tires easily Visual impairment Weakness Weight bearing status partial Psychosocial mood issues Anxiety Avoids care participation Depression Mood problem Motivation deficit Intervention Dis a Explain to resident that is time to eat N NA Devices Apply to resident Place near resident Put in resident s hand N NA Type Regular Spoon Fork Knife Built up Spoon Fork Knife N NA Rocker Spoon Fork Knife Plate guard Non skid device under plate Cup Sippe Deep dish plate N NA a Provide support Supervision Cues Demonstration Oneperson Feed as needed N NA a Remind resident to take small bites to chew and swallow each bite to use the tongue to move food in the mouth to avoid pocketing a Remove adaptive equipment a Goal Resident will demonstrate improvement in self feeding skills as evidenced
5. 303 426 9712 www restorativenursing com SIHH LO SHOIAHG ONICHA 115155 SIHASNV LL ALINEON CHa DNINIG SALLV IOLSH3 DNIINOOD DNISSHIG SHNOO SHOV IS SLNI IdS INOILOW LSTI XALSVW LIND SWV3IDO Id AATILVAOLSAY INOILV TNaN VI 5 YNO pz suoissas y 10 990 91 ejduiexa sjeniui uoisses sejnului Jo suononajsul sojnurm ONINIVYL SNIMOTIVMS L SNILV3 x TH ONINIVAL SNINOON9 L ONISSAYG HONV ISISSV HOVAA LNI IdS TH I SISHH LSO Id NO LV L ndlNV 5 TH od AT T WON 0 6086 12 92 ST vc c TT Ic Oc 61 SL 21 OL ST vt ET 21 11101 6 8 Z 9 g p JE 1 Fad HLNOW l33HS ONISUNN SAILVYOLSSY QUALITY INDICATOR RESIDENT LEVEL REVIEW PHYSICAL FUNCTIONING DOMAIN 18 Incidence of Decline in ROM Facility Comparison Group o Percentile Rank MDS ARD QI Report Period to MDS Items Involved G4a f Exclusions Residents with maximal loss of ROM at previous assessment Sum G4a f Bo
6. 6 days per week e A clinical record which Demonstrates evidence of periodic evaluation by the licensed nurse e Evidence that the nursing assistants aides have been trained in the techniques that promote resident involvement in the activity e Service delivery that demonstrates Training and skill practice Activities including repetition physical or verbal cueing and task segmentation provided by any staff member or volunteer under the supervision of a licensed nurse d Evidence that the nursing assistants aides have been trained in the techniques that promote resident involvement in the activity Carried out by nursing staff Or Presence of supervision by the nursing staff No more than 4 residents per group e For reimbursement purposes there must be 2 restorative nursing programs Consider the following when assessing the resident Does the resident have the ability to learn To what extent can the resident call on past memory to assist in current problem solving situations a Whatis the resident s general functional status suleJfoJg 210 210 210 210 jueuieDeue N eJnjoeJjuo2 o2Ue sisse aleg quljds SISOUISOId eoeJg JejsueJ uoneoiunuuoo 10 uoneinduwy 7 SONY eAngeJojseJ Sof 40 e se sjunoo
7. C MGS LNHA Janie Krechting BSN RN C MGS LNHA is a clinical consultant with expertise is on OBRA compliance PPS RUGS III MDS RAI quality improvement assessment documentation care planning management and supervision Krechting is also an assistant professor in aging services and administration at the College of Mount St Joseph in Cincinnati She is also the author of the books Clinically Based Long Term Care Survey Preparation Guide Manual and Interdisciplinary Care Plans for Long Term Care and the Quick Guide to Documentation BJ Collard RN BSN GNP ANP CPHQ BJ Collard RN BSN GNP ANP CPHQ is founder of CTS Inc a nurse consultation and education firm in Denver which specialized in post acute care CTS provides consultation services and workshops for organiza tions corporations and individuals Collard is an expert on OBRA compliance PPS RUGS III MDS RAI JCAHO quality improvement assessment documentation care planning management and supervision Collard devel oped and has presenting for 13 years a DON Training Program for corporations and individuals BJ is a recognized authority on restorative nursing having successfully completed a grant awarded to her from the Federal Administration on Aging to develop a model for systematic delivery of restorative nursing care to clients in post acute care settings This model has become the prototype used by all organizations to implement comprehensive successful restorative
8. reasons for problem and contributing factors gt Symptom Detailed description Goal gt Measurable key to progress measurement Target date nterventions What will be done schedule and who What equipment will be used schedule Resident teaching education to occur 37 Restorative Care Plan Problem Statement Example Self care deficit Eating Related to Loose dentures gt Right hemiplegia history of right hand dominant As evidenced by Food falls off plate when scooping with spoon Difficulty chewing meat Difficulty piercing food 38 20 Realize the Benefits of Restorative Nursing ExHiBIT Restorative Care Plan Goal Statement Example Resident will be able to gt Scoop soft items with spoon without pushing off plate chew meat pierce food by target date 39 Restorative Care Plan Intervention Example Place resident in restorative eating program each meal 7 day per week Use plate guard Coordinate dental referral Provide mechanical soft diet until ability to chew meat demonstrated Teach resident piercing skills 40 Realize the Benefits of Restorative Nursing 21 ExHiBIT ocheduling the lost link T Facility schedule Meals Ss Bath gt Activities Documentation of resident scheduling must be coordinated with facility schedule e g range of motion requiremen
9. you pass with flying colors PPS Alert for Long Term Care is your resource to navigate the confusing world of the MDS and keep you in the loop on CMS latest initiatives Created exclusively for the MDS coordinator or RNAC long term care administrator and director of nursing this dynamic publication will become your survival guide when it comes to complying with PPS It also gives you the latest compliance tips news and analyses regarding MDS coding timing and scheduling Plus you ll love our most popular feature in this 12 page monthly resource the PPS Q amp A column from noted expert Julia Hopp MS RN CNAA BC PPS Alert for Long Term Care is a user friendly tool that will lead you successfully through the MDS by offering tips on the best coding and documentation methods to getting the reimbursement you deserve For more information please call HCPro Inc customer service at 800 650 6787 Realize the Benefits of Restorative Nursing vii Speaker profiles Noelle Shough moderator Noelle Shough is senior managing editor in the long term care group Besides manning the helm of the newsletter PPS Alert for Long Term Care she edits books newsletters and e zines as well as manages quality for the group In her four and a half year stint at HCPro she has also written and researched in the areas of rehabilitation credentialing patient safety nurse management physician practices and compliance Janie Krechting BSN RN
10. Dial In Instructions Conference Name Realize the Benefits of Restorative Nursing How to improve reimbursement and your residents quality of life Scheduled Conference Date Friday September 24 2004 Scheduled Conference Time 1 00 p m 2 30 p m Eastern 12 00 p m 1 30 p m Central 11 00 a m 12 30 p m Mountain 10 00 11 30 a m Pacific 9 00 am 10 30 am ADT Alaska 8 00 am 9 30 am H AST Hawaii Aleutian Scheduled Conference Duration 90 Minutes PLEASE NOTE If the audioconference occurs April through October the time reflects daylight savings If your area does NOT observe Daylight Savings times will be one hour earlier Your registration entitles you to ONE telephone connection to the audioconference Invite as many people as you wish to listen to the audioconference on your speakerphone Permission is given to make copies of the written materials for anyone else who is listening In order to avoid delays in connecting to the conference we recommend that you dial into the audioconference 15 minutes prior to the start time Dial In Instructions Dial 1 973 321 1030 and follow the voice prompts You will be greeted by an operator Give the operator your pass code 092404 and the last name of the person who registered for the audioconference The operator will then verify the name of your facility You will then be placed into the conference Technical Difficulties 1 If you experience any difficul
11. F REPORTS PROGRAM STATUS TO NURSING ADMINISTRATION CONSULTS WITH STAFF WHEN PROGRAMS ARE NOT GOING AS EXPECTED CONSULTS WITH THERAPY AS INDICATED NURSES HOLDS CNAS ACCOUNTABLE FOR DOING THE PROGRAM AND DOCUMENTING THE PROGRAM KEEPS THE PROGRAM CURRENT ON THE UNIT MASTER LIST COMUNICATES PROGRAMS TO CNNAS VERBALLY AND IN WRITING ASSESSES RESIDENTS WHEN NOT RESPONDING TO THE PROGRAM AS EXPECTED CONSULTS WITH RESTORATIVE NURSE AND OR THERAPY AS IDICATED MDS COORDINATOR POINT PERSON OVERSEES CODING ACCURACY PARTICULAR EMPHASIS TO SECTION G CNAS IMPLEMENTS THE PROGRAMS DOCUMENTS THEPROGRAMS KEEPS CHARGE NURSE INFORMED OF STATUS OF THE PROGRAM DOCUMENTS AND COMMUNICATES WHEN THE PROGRAM IS NOT GOING AS EXPECTED THERAPY REFERRAL SOURCE DURING THERAPY UPON DISCHARGE UPON NOTIFICATION OF A RESIDENT S CHANGE IN FUNCTIONAL STATUS CONSULTANTS TOMORE COMPLEXT RESIDENTS EDUCATION LEVEL DELEGATED TASKS TRAINING SKILLS AND TECHNIQUES DON POLICIES PROCEDURES JOB DESCRIPTIONS ASSIGNS POSITION TO OVERSIGHT THEPROGRAM OVRSEES STAFFING AND CLINICAL SETS AND SUPPORTS POLICY THAT LEVEL II IS NOT THE IN HOUSE POOL STAFF MEETS WITH RESTORATIVE COORDINAOTR ON A CONSISTENT BASIS RESOURCES AND SUPPORT MAKES THE RESTORATIVE COORDINATOR ACCOUNTABLE QUESTIONS ABOUT QPS ETC ADMINISTRATOR SETS THE TONE SUPPORTS THE DEVELOPMENT COMMITTEE RESOURCES
12. Fe NM 21 22nd Legal Issues for Medical Leadership How to stay out of trouble and stay out of court Credentialing and Privileging What physician leaders and credentialing professionals must know today NOVEMBER The Ritz Carlton New Orleans New Orleans LA 4 5th Patient Safety and Medical Error Reduction How to identify and eliminate the real causes of medical error Advanced Medical Staff Leadership Retreat Il Leadership solutions for managing ongoing dilemmas The Ritz Carlton Palm Beach Palm Beach FL 17th VPMA Retreat Opportunities constraints and challenges of the VPMA CMO role 18 19th Medical Executive Committee Institute The essential training program for all medical staff leaders Effective JCAHO Survey Preparation for the Medical Staff 19 20th New Seminar Department of Surgery Institute For more information call 800 801 6661 or visit us on the Web at www greeley com Select seminars offer Category CME Nursing Contact Hours and NAMSS CEU s 2004 The Greeley Company a Division of HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations which owns the JCAHO trademark
13. and improvement areas ExHiBIT Realize the Benefits of Restorative Nursing How to improve reimbursement and your residents quality of life September 24 2004 B J Collard RN BSN GNP ANP CPHQ a Janie Krechting BSN RN C MGS LNHA What is Restorative Nursing Not to be confused with formalized therapy services that are provided by or under the direction of qualified therapists speech language pathology occupational therapy and physical therapy Restorative Nursing is a Nursing function Realize the Benefits of Restorative Nursing ExHiBIT What is Restorative Nursing CMS Definition Rehabilitation or restorative care refers to nursing interventions that promote the resident s ability to adapt and adjust to living as independently and safely as is possible This concept actively focuses on achieving and maintaining optimal physical mental amp psychosocial functioning What is a Restorative Nursing Program MDS section p3 1 program vs two Passive or active ROM Splint or brace assistance Bed mobility Transfer Walking Dressing grooming Eating swallowing Amputation prosthesis care Communication training Toileting or bladder retraining Realize the Benefits of Restorative Nursing 3 ExHiBIT What is a Restorative Nursing Program THE FOUR P s Promoting Preserving Prevent
14. by will feed self independently with verbal cues with limited assist with extensive assistance 9e of each meal by through Resident will feed self finger food pierce food with fork Scoop with a spoon Bring cup to mouth independently with verbal cues with limited assist with extensive assistance by through Resident will need less eating support as evidenced by no support person support through Resident will maintain current support level as evidenced by support one person support through N NA Signature Title Date s Restorative Progress Notes Eating Month Year DATE 1 2 3 4 5 6 7 8 9 110111 12 13 14 15 Time Breakfast Minutes Lunch Minutes Dinner Minutes Response Initials DATE 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Breakfast Minutes Lunch Minutes Dinner Minutes Response Initials Response Key T Tolerated R Refused Health appointment 5 Sick See appetite flow sheet for percentage of meal consumption Progress Notes Evaluation Result Improvement Maintenance Resident required verbal cues for eating Resident required limited assistance for eating Resident required extensive assistance with eating Discuss presence of the following issues spillage from the fork spoon plate or po
15. c analysis Two excellent tools Quality indicators Quality measures Benchmarking 47 QI to Identify Improvement Areas Enhance best practices Maintain systems that function as planned amp expected Sustain delivery of quality of care and compliance over time 48 Realize the Benefits of Restorative Nursing 25 EXHIBIT 26 Realize the Benefits of Restorative Nursing Exhibit B Restorative nursing tools provided by Janie Krechting Restorative nursing program components checklist Restorative nursing programs chart Restorative reimbursement analysis chart Restorative program Eating checklist and progress table Restorative nursing referral form Restorative nursing assignment sheet and master list Source Permission to reprint by Janie Krechting BSN RN C MGS LNHA Restorative Nursing Program Components Each of the following components are required for the establishment of a restorative nursing program An assessment which Demonstrates the need for the program Iscompleted by a Licensed nurse d Does not include procedures or techniques carried out by or under the direction of qualified therapists Acare plan which d Includes measurable goals objectives d Includes specific interventions for the need identified through the assessment e A service delivery record which Demonstrates service delivery at least 15 minutes a day
16. cketing of food difficulty swallowing or chewing and referral needs Signature Title Restorative Nursing Referral Form Date Resident Reason for referral Resident would benefit from the following program s Resident no longer appropriate for therapy but would benefit from ongoing intervention Describe specific issue Suggested Program s Amputation Bed Mobility Brace assistance Communication Dressing Eating Dining Grooming Prosthesis Care Range of Motion Splint assistance Swallowing Toilet in Advance of Need Scheduled toileting Transfer Training Walking ambulation Referral Source Physical Therapy MDS Department Nursing Staff Dietary Department Activity Department MDS Department MDS Department Signature Title en n n Aepinyes J Aepsoupo m epung Wm sjuopisoq pousIssy opry 19945 5 DuisinN 5 sjuouro pojsoSsng UIeJ3OJq 15171 Jojse A SUISINN 5 35 Realize the Benefits of Restorative Nursing Exhibit C Restorative nursin
17. d practices organization structure Job descriptions Policies amp procedures Orientation ongoing training amp education Skills competency 22 Realize the Benefits of Restorative Nursing ExHiBIT How Do You Organize a Facility Program Staff need to know Restorative care is taken seriously and they are expected to follow through organization structure Accountability tracking amp monitoring Call in policy Nursing management amp administration need to know program outcomes program function organization structure Quality indicators Quality measures 23 WHAT WHO WHERE WHEN WHY HOW 24 Realize the Benefits of Restorative Nursing 13 ExHiBIT Restorative Nursing Requires a Team My supervisxr txld me that team wxrk depends xn the performance xf every single persxn xn the team lignxred that idea until my supervisxr shxwed hxw the xffice typewriter perfxrms when just xne single key is xut of xrder All the xther keys wxrk just fine except xne But that xne destrxys the effectiveness xf the typewriter Nxw knxw that even thxugh am xnly xne persxn am needed if the team is tx wxrk as a successful team shxuld 25 Restorative Programs 57 Janie Krechting Assistant Professor College of Mount St Joseph 26 14 Realize the Benefits of Restorative Nursing Structure Process and Systems and R
18. e Marketplace www hcmarketplace com Looking for even more resources You can shop for the healthcare management tools you need at HCPro s Healthcare Marketplace www hcmarketplace com Our online store makes it easy for you to find what you need when you need it in one secure and user friendly e commerce site At HCPro s Healthcare Marketplace you ll discover all of newsletters books videos audioconferences online learning special reports and training handbooks that HCPro has to offer Shopping is secure and purchasing is easy with a speedy checkout process 48 Realize the Benefits of Restorative Nursing OJdOH euuezng vOOZ rz 1 uO 06 JO NO sjuepisey eAo1duJ DuisinN JO sjjeueg eui OZP JO 3191511432 A rca od cfr The Greeley Company in Facirhcans Coeubing amd Trang Education Program Schedule Fal 2 004 Loews Philadelphia Hotel Philadelphia eth The Problem Physician How to assess and manage impaired dyscompetent and disruptive physicians 7 8 Medical Staff Quality How to improve peer review patient safety and clinical outcomes Advanced Medical Staff Leadership Retreat I How to resolve today s toughest medical staff challenges Eldorado Hotel Santa
19. ended solely for use in conjunction with the associated HCPro audiocon ference Licensee may make copies of these materials for your internal use by attendees of the audioconference only All such copies must bear this legend Dissemination of any information in these materials or the audiocon ference to any party other than the Licensee or its employees is strictly prohibited Advice given is general and attendees and readers of the materials should consult professional counsel for spe cific legal ethical or clinical questions HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations which owns the JCAHO trademark For more information contact HCPro Inc 200 Hoods Lane P O Box 1168 Marblehead MA 01945 Telephone 800 650 6787 Fax 781 639 0179 E mail customerservice hcpro com Web www hcpro com Realize the Benefits of Restorative Nursing iii 2252 lt ela gt Marblehead MA 01945 Pro 200 Hoods Lane P O Box 1168 Tel 800 650 6787 Fax 800 639 8511 Dear colleague Thank you for participating in our Realize the Benefits of Restorative Nursing How to Improve Reimbursement and Your Residents Quality of Life audioconference with B J Collard RN BSN GNP ANP CPHQ and Janie Krechting BSN RN C MGS LNHA moderated by Noelle Shough We are excited about the opportunity to interact with you directly and encourage you to take advantage of the opportunity to a
20. estorative Documentation Structure Policies and procedures gt Training orientation gt Tools Forms Restorative equipment Restorative monitors Process Identify and train individuals in positions required to document Restorative nurse Restorative aide Activity staff or other staff trained to deliver restorative nursing program Realize the Benefits of Restorative Nursing ExHiBIT ExHiBIT Required documents Restorative nursing assessment Restorative care plan Delivery record Progress note Other required documents e Documentation to support training and competency of restorative nursing assistants delivering care 16 Realize the Benefits of Restorative Nursing ExHiBIT Let s start from the very beginning it s a very good place to start Identify residents appropriate for restorative nursing assessment then utilize documents forms communication tools gt Therapy to nursing form A form that notifies nursing of residents appropriate for evaluation New admission process should include an evaluation form or documentation of need for restorative program Resident changes indicating need for new restorative nursing evaluation form or process for communication with restorative nurse 31 Which documents by whom and A restorative assessment completed by qualified r
21. estorative nurse upon referral Arestorative care plan developed by the restorative nurse to reflect individual resident s assessed needs Adelivery record completed by restorative nursing assistants trained activity assistants after each session A progress note by restorative nurse monthly and or quarterly note Not a co signature 32 Realize the Benefits of Restorative Nursing 17 ExHiBIT Restorative Nursing Documentation Process Data Gathering Assessment Analysis Evaluation Care Plan Implementation Documentation 2 programs 15 minutes 6 days per week Data Gathering Process Observation Interview Documentation Hospital discharge records gt Therapy notes Flow records Nursing notes Delivery record Nursing progress note Realize the Benefits of Restorative Nursing ExHiBIT Assessment Assessment tool choices Narrative assessment Assessment tool Generic Specific to condition being assessed 35 Assessment Content Consider strengths and weaknesses Risks and potential complicating factors Restorative program or maintenance Resident specific deficit indicating need for restorative program 36 Realize the Benefits of Restorative Nursing 19 ExHiBIT Restorative Care Plan Documentation Problem PES gt Problem statement General category gt Etiology Risk factors
22. euo 210 e se sjunoo euo d ON 10 eAneojse1 sjunoo euo A UO 10 SONY 40 ueJ604d ese sunos euo AluO eIoN uoneinquiy Buiu004c BuisseJq Ul JejJo Jeppeig Aygo peg Jo Bune3 UOI O N BUISJINN 5 uonounJ jeoisAud MOJ uoniubo5 qeyoy 1511 5 1511 euo si 451 sureJ6oJd Jeuonippe 2 Z 10 1 U Od 5 5 SONY 53 59 Adesay uoneyiqeueJ oym JO jeois yd au ur OUM sjuepise 1517 eys sis Jeuy 5 Restorative Program Eating Assessment Eating Factors impacting eating skills Fine motor skills impaired Hemiplegia right left Pain Vision impaired Eating skills Holds Brings cup glass to mouth food with fork Scoops food with spoon
23. formance in dressing and undressing bathing and washing and performing other personal hygiene tasks h Eating or swallowing Activities used to improve or maintain the residents self performance in feeding one s self food and fluids or activities used to improve or maintain the resident s ability to ingest nutrition and hydration by mouth i Amputation Prosthesis Care Activities used to improve or maintain the resident s self performance in putting on and removing a prosthesis caring for the prosthesis and providing appropriate hygiene at the site where the prosthesis attaches to the body e g leg stump or eye socket j Communication Activities used to improve or maintain the resident s self performance in using newly acquired functional communication skills or assisting the resident in using residual communication skills and adaptive devices k Other Any other activities used to improve or maintain the resident s self performance in functioning This includes but is not limited to teaching self care for diabetic management self administration of medications ostomy care and cardiac rehabilitation ROLES AND RESPONSIBILITIES IN RESTORATIVE NURSING RESTORATIVE NURSE COORDINATOR LIASON BETWEEN THERAPY amp NURSING OVERSIGNTS THE PROGRAM HOW ARE PROGRAMS GOING PROBLEM SOLVE WHEN PROGRAMS ARE NOT GOING AS EXPECTED ORGANIZES THE PROGRAM WORKS WITH NURSES TO SEE PROGRAMINFORMATIONIS CURRENT 1 1 WITH STAF
24. g tools provided by B J Collard The four P s of restorative nursing Roles and responsibilities in restorative nursing Restorative nursing transfer and documentation form Restorative program unit master list Restorative nursing flow sheet Quality indicator resident level review Source Permission to reprint by B J Collard RN BSN GNP CPHQ FOUR P S OF RESTORATIVE NURSING BASIC PROGRAMS FOCUS 1 Ambulation Programs Promote Mobility 2 Incontinent Management Promote Bowel and Bladder Function 3 Range of Motion ROM Programs Prevent Contractures 4 Skin Management Prevent Skin Breakdown 5 ADL and Restorative Dining Programs Promote Ability to Perform ADLS 6 Sensory Stimulation Classes Preserve Orientation Level Cognitive Orientation Classes 7 Socialization Opportunities and Activities Preserve Emotional Health and One to One programs Promote Social Functioning 8 Communication Programs and Promote Communication Interventions 9 Integration of Religious Spiritual Daily Routine Promote spiritual well being 10 Assistance With Dealing With End of Life Issues Prepare for Death RESTORATIVE PROGRAMS UNDER MDS SECTION P3 a Range of Motion Passive The extent to which or the limits between which a part of the body can be moved around a fixed point or joint Range of motion exercise is a progam of passive or active movements to maintain flexibility and useful motion in the
25. ing Preparing What is a Restorative Nursing Program A specific approach that is organized planned documented monitored and evaluated 4 Realize the Benefits of Restorative Nursing What is a Restorative Nursing Program Prescription for a Program Whatis to be done 1 2 3 Whois to do it 4 When where What specific equipment staff assistance etc What is a Restorative Nursing Program Program Classifications Improve function Progressive Maintain function Functional maintenance Skills practice Prevent decline or slow decline Functional modify Realize the Benefits of Restorative Nursing ExHiBIT ExHiBIT What is a Restorative Nursing Program What if no expectations of improvement s this a program Yes A few examples What Residents Need a Restorative Program Aresident who is unable to perform an ADL function or segments of a function independently at a point in time bust has potential for Independent task or subtask performance Maintaining task or subtask function with staff intervention Preventing or slowing decline with staff intervention Realize the Benefits of Restorative Nursing ExHiBIT RESIDENT PROFILES FOR PROGRAM CLASSIFICATIONS i 2 gt 11 When is the Best Time to Provide Programs Dependent upon the resident Indi
26. joints of the body b Range of motion Active Exercises performed by a resident with cueing or supervision by staff that are planned scheduled and documented in the clinical record c Splint or brace assistance Assistance can be of 2 types 1 when staff provide verbal and physical guidance and direction that teaches the resident how to apply manipulate and care for a brace or splint or 2 where staff have a scheduled program of applying and removing a splint or brace assess the resident s skin and circulation under the device and reposition the limb in correct alignment these sessions are planned scheduled and documented in the clinical record Training and skill practice in Activities including repetition physical or verbal cueing and task segmentation provided by any staff member or volunteer under supervision of a licensed nurse d Bed mobility Activities used to improve or maintain the resident s self performance in moving to and from a lying position turning side to side and positioning him or herself in bed e Transfer Activities used to improve or maintain the resident s self performance in moving between surfaces or planes either with or without assistive devices f Walking Activities used to improve or maintain the resident s self performance in walking with or without assistive devices g Dressing or grooming Activities used to improve maintain the residents self per
27. m has been carried out by staff as stated on the care plan Is staff observed to be carrying out the program during observation today 5 Was therapy indicated If no explain 6 Is there documented evidence the Resident Assessment Protocol RAP for physical functioning was reviewed Conclusion Summary Avoidable Unavoidable Resident Sample ID Number Was the MDS scored accurately during the assessment period Was there documented evidence staff had addressed the risk for contractures Was there documented evidence the staff had addressed the decline Was a Restorative Nursing ROM Program indicated If no explain If yes answer the following questions Was the program on the care plan Is there documented evidence the program has been carried out by staff as stated on the care plan Is staff observed to be carrying out the program during observation today 5 Was therapy indicated If no explain 6 Is there documented evidence the Resident Assessment Protocol RAP for physical functioning was reviewed Conclusion Summary Avoidable Unavoidable IV Resident Sample ID Number Was the MDS scored accurately during the assessment period Was there documented evidence staff had addressed the risk for contractures Was there documented evidence the staff had addressed the decline Was a Restorative Nursing ROM Program indicated If no explain If yes answer the following que
28. nursing programs Collard contracts with corporations to perform restora tive nursing program analysis and directs program revision development and system implementation based on identified strengths and improvement areas Collard is a charter member of AANAC and serves on AANAC s board of directors Collard has authored many publications and her two most popular manuals are the Restorative Nursing Manual and the Quality Improvement Manual for LTC The Restorative Nursing Manual is a practical guide that will assist facility staff to provide restorative care in a systematic planned manner that enhances individual resident quality of life meets RUGS III PPS payment criteria and achieves CMS compliance with OBRA regulations The Quality Improvement Manual provides tools forms and resources to set up a facility quality improvement pro gram The manual includes a chapter on a process on how to use the quality indicator data and reports to per form root cause analysis of the OBRA regulations are set up as QI tools and can be used as a resource for learning the regulations as well as to perform a mock survey self assessment viii Realize the Benefits of Restorative Nursing Exhibit A Presentation by B J Collard RN BSN GNP and Janie Krechting BSN RN C MGS LNHA Agenda 1 Overview of restorative nursing 2 Documentation requirements 3 Reimbursement considerations 4 Quality indicators to measure success
29. ogram Eating checklist and progress table Restorative nursing referral form Restorative nursing assignment sheet and master list ile occ 2 20 Restorative nursing tools provided by B J Collard The four P s of restorative nursing Roles and responsibilities in restorative nursing Restorative nursing transfer and documentation form Restorative program unit master list Restorative nursing flow sheet Quality indicator resident level review ROSOUICOS uie E oe prs 30 Realize the Benefits of Restorative Nursing vi Agenda 1 Overview of restorative nursing 2 Documentation requirements 3 Reimbursement considerations 4 Quality indicators to measure success and improvement areas Q amp A Realize the Benefits of Restorative Nursing About your sponsors About HCPro Inc HCPro is the premier healthcare information and resource provider on compliance and regulatory issues faced by hospitals home health organizations nursing homes physicians offices and other healthcare facilities HCPro has launched a number of Web supersites that include tips how to information ask the expert columns free e mail newsletters and so much more About PPS Alert for Long Term Care Survey deficiencies the DAVE project quality measures every time you turn around CMS has found a new way to test under MDS accuracy Let PPS Alert for Long Term Care help
30. r Residents Quality of Life A 90 minute interactive audioconference Friday September 24 2004 1 00 p m 2 30 p m Eastern 12 00 p m 1 30 p m Central 11 00 a m 12 30 p m Mountain 10 00 a m 11 30 a m Pacific i 5 A Pro In our materials we strive to provide our audience with useful timely information The live audioconference will follow the enclosed agenda Occasionally our speakers will refer to the materials enclosed We have noticed that other non HCPro audioconference materials follow the speaker s presentation bullet by bullet page by page Because our presentations are less rigid and rely more on speaker interaction we do not include each speaker s entire presentation The materials contain helpful forms crosswalks policies charts and graphs We hope that you find this information useful in the future HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations which owns the JCAHO trademark Realize the Benefits of Restorative Nursing Am Pro The Realize the Benefits of Restorative Nursing How to Improve Reimbursement and Your Residents Quality of Life audioconference materials package is published by HCPro 200 Hoods Lane P O Box 1168 Marblehead MA 01945 Copyright 2004 HCPro Inc Attendance at the audioconference is restricted to employees consultants and members of the medical staff of the Licensee The audioconference materials are int
31. safety 2 Safety Realize the Benefits of Restorative Nursing 47 RESOURCES HCPro offers the news and tips you need at the touch of a button sign up for our informative FREE e mail newsletters check out our in depth how to information in our premium newsletters and get advice from our knowledgeable experts The Greeley Company www greeley com Get connected with leading healthcare consultants and educators at The Greeley Company s Web site This online service provides the fastest most convenient and most up to date information on our quality consulting national education offerings and multimedia training products for healthcare leaders Visitors will find a com plete listing of our services that include consulting seminars and conferences If you re interested in attending one of our informative seminars registration is easy Simply go to www greeley com and take a couple of minutes to fill out our online form Visitors of www greeley com will also find Faculty and consultant biographies learn about our senior level clinicians administrators and faculty who are ready to assist your organization with your consulting needs seminars workshops and symposiums Detailed descriptions of all The Greeley Company consulting services A List of Greeley clients Catalogue and calendar of Greeley s national seminars and conferences and available CMEs User friendly online registration order forms for seminars HCPro s Healthcar
32. sk our experts your questions during the audioconference If you would like to submit a ques tion before the audioconference please send it to sdunn hcpro com and provide the program date in the subject line We cannot guarantee your question will be answered during the program but we will do our best to take a good cross section of questions If at any time you have comments suggestions or ideas about how we might improve our audioconference or if you have any questions about the audioconference itself please do not hesitate to contact me And if you would like any additional information about other products and services please contact our Customer Service Department at 800 650 6787 Thanks again for working with us Best regards oe ae Shara M Dunn Audio Web Conference Coordinator Fax 781 639 2982 E mail sdunn hcpro com Realize the Benefits of Restorative Nursing Contents CL vi About Your 5 vii Speaker Profiles iik a a Ra x ax wx y viii eek 1 Presentation by BJ Collard RN BSN GNP and Janie Krechting BSN C MGS LNHA EU mp IU CPP pepe 11 Restorative nursing tools provided by Janie Krechting Restorative nursing program components checklist Restorative nursing programs chart Restorative reimbursement analysis chart Restorative pr
33. stions Was the program on the care plan Is there documented evidence the program has been carried out by staff as stated on the care plan Is staff observed to be carrying out the program during observation today 5 Was therapy indicated If no explain 6 Is there documented evidence the Resident Assessment Protocol RAP for physical functioning was reviewed Conclusion Summary Avoidable Unavoidable V Resident Sample ID Number Was the MDS scored accurately during the assessment period Was there documented evidence staff had addressed the risk for contractures Was there documented evidence the staff had addressed the decline Was a Restorative Nursing ROM Program indicated If no explain If yes answer the following questions Was the program on the care plan Is there documented evidence the program has been carried out by staff as stated on the care plan Is staff observed to be carrying out the program during observation today Was therapy indicated If no explain Is there documented evidence the Resident Assessment Protocol RAP for physical functioning was reviewed Conclusion Summary Avoidable Unavoidable Use the Quality Indicator Facility System Level Review Form to apply the QI process when improvement areas are identified When there are no areas needing improvement report through and file the documentation Share the positive outcomes with your staff
34. t information will be provided along with the pro gram materials Please follow the instructions provided in the CE Documentation NS 200 Hoods Lane PO Box 1168 Marblehead 01945 781 639 1872 781 639 7857 URL www hcpro com Program Evaluation Dear Audioconference Participant Thank you for attending the HCPro audioconference today We hope that you find the information provided valuable In our effort to ensure that our customers have a positive experience when taking part in our audioconferences we are requesting your feedback We would also like to request that you forward the link to others in your facility that attended the audioconference We realize that your time is valuable so we ve limited the evaluation to nine multiple choice questions Please click on the link below http www zoomerang com survey zgi p WEB2QF5RKS36A The information provided from the evaluation is crucial towards our goal of delivering the best possible products and services We appreciate your time and suggestions We hope that you will continue to rely on HCPro audioconferences as an important resource for pertinent and timely information Sincerely Le Zee Frank Morello Director of Multimedia HCPro Inc PPS Alert lert A Survival Toot THE MDS or RN COORDINATOR presents Realize the Benefits of Restorative Nursing How to Improve Reimbursement and You
35. ties with the dial in process please call the Conference Center reservation line at 973 633 8500 2 If you should need technical assistance during the audio portion of the program please press the key followed by the O key on your touch tone phone and an operator will assist you If you are disconnected during the conference dial 973 633 8500 Q amp A Session 1 To enter the questioning queue during the Q amp A session callers need to push the star key followed by the 1 key on their touch tone phones Note This portion of the program generally falls after the first hour of presentation Please do not try to enter the queue before this portion of the program 2 If you prefer not to ask your question on the air you can fax your question to 1 877 865 4210 or 1 973 237 3904 Please note You can only fax your question during the program Prior to the program If you prefer not to ask your question on the air you can send your questions via email to sdunn hcpro com Cutoff date and time for questions 09 23 04 5 30 PM EST Please note that not all questions will be answered Program Evaluation Survey In your materials on page 2 we have included a Program evaluation letter that has the URL link to our program survey We would appreciate it if when you return to your office you could go to the link provided and complete the survey Continuing Education documentation If CE s are offered with this program a separate link containing importan
36. torative Dining program Skill practice will continue in the Restorative Dining program See goal and program above Hazel Nut LPN Restorative Nurse Weekly Progress 4 8 04 Resident was able to place utensils in her hands when staff handed the utensils to her She drops the utensil approximately 4 5 times at each meal and more frequently at supper as she reports she is tired by dinner She is using the utensils for approximately 25 of meals Will continue goal and program Hazel Nut LPN Restorative Nurse Weekly Progress 4 15 04 Resident has increased her ability to use her utensils and is able to use them without dropping them for 50 of all meals Goal was changed to 100 of all meals by 4 3 04 Hazel Nut LPN Restorative Nurse Weekly Progress 4 22 04 Resident is able to feed herself 100 of breakfast with no interventions from the CNA and without dropping utensils She requires staff placement of their hands firmly on hers approximately 2 3 times for lunch and supper Hazel Nut LPN Restorative Nurse Weekly Progress 4 29 04 Resident is able to use her utensils to feed herself all 3 meals most of the time She occasionally needed staff firm hand placement a few times at supper and dropped her fork once during lunch Will keep her in Restorative Dining for one more week to assure she is able to handle her utensils independently then will transfer to level III regular dining room Hazel Nut LPN Restorative Nurse CTS INC
37. ts dictate schedule 4i Steps to maximizing RUGs III restorative nursing reimbursement T e Identify residents whose RUGS score falls into categories impacting reimbursement e Identify residents who only have one restorative program Review residents with significant changes 22 Realize the Benefits of Restorative Nursing ExHiBIT Restorative Reimbursement Identify residents that fall in the categories in which restorative nursing has an impact Rehabilitation low Impaired cognition Behavior impaired Reduced physical functioning 43 Group therapy Mns What is it The delivery of restorative services in a group setting gt MDS criteria No more than 4 persons per restorative nursing assistant Implementation considerations Daily scheduling of resident s ADL s Staff communication and coordination 44 Realize the Benefits of Restorative Nursing 23 ExHiBIT Costs of not having a high quality restorative nursing program Higher acuity Quality of life Depression Lost restorative reimbursement Survey citations Census reputation QI to Measure Success Identify amp celebrate staff efforts successes Illustrate what you are An doing right 24 Realize the Benefits of Restorative Nursing ExHiBIT QI to Identify Improvement Areas Ongoing to see how you are doing planned systemati
38. ure Title Date CTS Inc Nurse Consultants and Educators 303 426 9712 www restorativenursing com Copyright 2002 BJ Collard CTS Inc 1 Resources Sky Pro Other sites Collard RN BSN GNP ANP CPHQ CTS Inc 2714 West 119th Avenue Westminster CO 80234 Phone 303 426 9712 E mail bcollard mindspring com Web site www restorativenursing com Janie Krechting BSN RN C MGS LNHA College of Mount St Joseph 5701 Delhi Road Cincinnati OH 45233 1670 Phone 513 244 4588 E mail Janie_Krechting mail msj edu HCPro sites HCPro www hcpro com RESOURCES With more than 17 years of experience HCPro Inc is a leading provider of integrated information education training and consulting products and services in the vital areas of healthcare regulation and compliance The company s mission is to meet the specialized informational advisory and educational needs of the healthcare industry and to learn from and respond to our customers with services that meet or exceed the quality they expect Visit HCPro s Web site and take advantage of our online resources At hcpro com you ll find the latest news and tips in the areas of gt Accreditation gt gt Corporate compliance gt gt Credentialing gt gt Health information management gt nfection control gt gt Long term care gt gt Medical staff gt Nursing 2 Pharmacy gt gt Physician practice gt gt Quality patient
39. vidualize schedule Sleeping patterns Peak performance shift involvement 24 7 Day shift Evening shift Night shift Realize the Benefits of Restorative Nursing 7 ExHiBIT Why is it Necessary to Provide Restorative Care Resident dignity amp self worth Increased staff morale Federal government regulations Reimbursement Decrease in staff time for ADL Marketing opportunity enhanced reputation WHO Identifies Restorative Needs amp Starts Programs Therapy Nursing 8 Realize the Benefits of Restorative Nursing Who Directs the Program Who Does What Restorative nurse coordinator Nurses CNAs Therapy MDS Coordinator Social Services Activities DON Administrator How to Deliver Restorative Care Which model is best No designated RCNAs versus designated restorative CNAs 2 levels No designated RCNAs Realize the Benefits of Restorative Nursing ExHiBIT ExHiBIT Designated Restorative CNAs 3 Levels Level I Level Il Level Ill Therapy Designated unit CNAs CNAs How to Deliver Restorative Care Which model is best Designated restorative No designated CNAs restorative CNAs High therapy usage Low therapy usage Large facility Small facility 80 Unit CNAs are still beds and below involved All CNAs equally involved
40. x A is 12 on previous assessment Numerator Residents with increases in functional limitation in ROM between previous and most recent assessments Denominator All residents with previous and most recent assessments with the exclusions noted Risk Adjustment None Resident Sample ID Number I 1 Was the MDS scored accurately during the assessment period 2 Was there documented evidence staff had addressed the risk for contractures 3 Was there documented evidence the staff had addressed the decline 4 Was a Restorative Nursing ROM Program indicated If no explain If yes answer the following questions Was the program on the care plan Is there documented evidence the program has been carried out by staff as stated on the care plan Is staff observed to be carrying out the program during observation today 5 Was therapy indicated If no explain 6 Is there documented evidence the Resident Assessment Protocol RAP for physical functioning was reviewed Conclusion Summary Avoidable Unavoidable II Resident Sample ID Number Was the MDS scored accurately during the assessment period Was there documented evidence staff had addressed the risk for contractures Was there documented evidence the staff had addressed the decline Was a Restorative Nursing ROM Program indicated If no explain If yes answer the following questions Was the program on the care plan Is there documented evidence the progra
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