Rehab and ADLs

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L
Since MDS 3.0 was initiated in October 2010, facilities throughout the United States have experienced a significant increase in “A” ADL scoring ratios.

According to the RUGs payment system (prior RUG-III and current RUG-IV), the late loss activities of daily living (ADL) component determines the final reimbursement rate of the applicable RUG category. The late loss ADLs comprise bed mobility, transfers, toileting and eating skills. If a resident is independent in all areas, he or she receives the letter score of “A.” The more dependent the resident, the higher the letter score.

Prior to MDS 3.0, the scoring algorithm basically allowed us to score more residents at a “B” level or higher. RUG-III gave us more credit for providing these services to our residents. MDS 3.0 and RUG-IV had minimal changes to the scoring methods; however, it significantly changed the scoring algorithm.

We continue to document how much assistance is required for the late loss ADLs, and continue to use the same verbiage for self-performance and staff support. By changing the scoring algorithm, they no longer give us as much “credit” as we received with the MDS 2.0 and RUG-III system. This has resulted in a significant increase in RUG categories receiving the “A” ADL scoring component, and receiving the least amount of reimbursement for each RUG.

So enough of the bad news … by becoming aware of your facility's trends, there are many different ways you can improve this predicament, and receive the proper reimbursement for the services you're providing. The typical mantra is “take credit for what you're doing.”

We spend many hours and valuable resources training our employees to document properly and understand definitions of what they should take credit for. This is STEP 1. As an OTR, I feel I have a better insight for task analysis of the ADL components. However, training should be targeted to the education level and learning styles of the trainees.

STEP 1 involves routine, possibly quarterly, ADL training sessions. Use real-life scenarios of residents at your facility and ask the trainees how they would score the ADL component of your scenario. This technique has been proven very successful because it promotes discussion and brainstorming, which helps to deepen the level of understanding.

STEP 2 is removing old assumptions and bad habits. There is no regulation, nor does it indicate in the RAI Manual that only CNAs and/or nursing can document and capture the scoring for the ADL component. STEP 2 is looking beyond your tools and thinking outside the box.

When collecting documentation for the MDS coding, consider the therapy notes and evaluations. Many times, PT and OT will document on all areas of the ADL components in Section G of the MDS on the initial evaluation. If your rehab departments document daily or weekly, look for the status of the ADL and mobility goals.


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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.