The conventional wisdom for improving Activities of Daily Living is to educate, reeducate and then educate again.

Education is important, as we need to capture the correct functional level the resident is currently preforming. But I also look at ADL capture as a process. Every process has gaps that can be narrowed or even closed.

Individual facilities may have different issues with the process. Usually 80% of ADL-capturing problems are caused by one or two gaps in the process. These gaps are unique to the facility based on staff strengths and weaknesses.

The process starts with the resident entering the facility. Ask:

  • Do we have the form filled out and in the place that the C.N.A can capture the ADLs immediately? (if on paper documentation)
  • Do we have the resident admitted to the electronic medical record before the current shift goes home? If not how do they capture the admission ADLs? (for electronic medical records facilities)

    Early ADLs are often the highest. Admission ADLs are important to capture and capture correctly. Capturing correctly means we capture the ADLS at the level the resident actually performed, not what the staff thinks the resident is capable of.

Next up: Look at the staff’s knowledge of being able to code the ADLs correctly. This is where we spend a lot of our time and efforts.

Formal education is important. But you have to ask whether staff member can explain what a functional level means to you or even define a level, while still being able to apply that information in a real situation. That means education along with formal auditing is extremely important. Every staff member who is involved with the ADL documentation process should be on the audit list. This includes therapists! I still come across forms that have “Min A” listed as limited assist.

Next step in the process is following up on the audit. That assures your staff is actually documenting the correct level. For example, staff members, upon audit, may be able to tell you verbally, “Mrs. Smith is an extensive assist for transfer.” But six residents later and five minutes before the end of the shift, that staff member may remember Mrs. Smith’s transfers were as limited assist.

If you are using written documentation system, one of the main problems is copycat documentation. It is easy to do when you have several residents to document. But when you are short on time, the brain remembers events differently when it is given a cue. EMR systems can cause issues with copycat documentation. Some bring up the resident care “planned level of function.” The staff then documents that level instead of the resident’s actual performance. 

Another tip: Choosing the Assessment Reference Date is an important step not to miss in your analysis. Often facilities will chose Day 8 for all of their five-day assessments. Doing this means that the ADLs on day one of the resident’s admission will not count in the seven-day-lookback.

This is can lead to a lower RUG and reimbursement. ADLs can show the resident at a higher level of dependency. For scheduled PPS assessments, look at late-loss ADL scores in the same manner that you would address therapy minute totals. Choosing the date that maximizes the overall RUG CMI will assure that you are not missing reimbursement opportunities.

The ADL capture process on the MDS is the last step. Auditing the MDS to assure that the ADLs follow the rules of Section G in the RAI manual is extremely important. Most EMRs pull the ADLs from the C.N.A. ADL module.

Every facility is different. You may have an extra step or two in your process. What is important is to lay out your ADL capture process. Then audit each step in the process to determine your gaps. Then fix the gaps and audit again. Unfortunately, with the turnover in skilled nursing homes today, this is a process that should be ongoing. 

Stacy Darling, MBA, MPT, AT, RAC-CT, is Vice President of Operations at Post Acute Consulting.