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MDS 3.0 Section F Preferences for Customary Routine and Activities:
Activity Professional Q and A
Here's just some of the questions I've received with my responses. Please share your knowledge and experiences as well!
1) I don’t see section F on the quarterly? When is section F completed?
Section F, Preferences for Customary Routine and Activities, is completed any time a comprehensive assessment is conducted:
- Admission Assessment
- Annual Assessment
- Significant Change Assessment
- Significant Correction of a Prior Full
2) Who completes section F?
Which individual or department is completing various sections of the MDS 3.0 varies from facility to facility. There are reports of Activity Professionals completing the following:
- All of the resident interviews, in addition to section F
- Some of the interviews (mood, cognition, and/or preferences)
- None of the interviews or sections of the MDS 3.0
- Some facilities are training each member of the IDT to conduct the complete interview and then taking turns in conducting the interviews.
- The most common, however, appears to be that the Activity Professional is completing all of section F
3) Do I still have to do quarterly notes even though section F is not in the quarterly MDS?
Just because section F is not included in the quarterly MDS, does not mean the Activity Department shouldn’t continue with their quarterly progress notes or other episodic notes. It is very important that the Activity Professional monitor each resident’s responses to activities and any activity interventions in accordance with the care plan. Quarterly and episodic notes help the Activity Professional to determine if changes should be made to care plans or if a change in the type of programming provided is needed.
4) Should I change my Activity Assessment?
Many Activity Directors are changing their Activity Assessments to be more compatible with the MDS 3.0. It’s really an individual choice. Look at your current Activity Assessment and be sure it doesn’t have any old MDS 2.0 language. If so, you may want to remove that and replace with current MDS 3.0 language. The Activity Assessment must provide the assessor with information that is necessary to plan a program of activities for the resident based on the resident’s individual need, interests, and preferences. Areas to consider include but are not limited to:
- Current, past and potential activity interests
- Potential barriers to activities such as psychosocial, cognitive, physical or health
- Family and community involvement
- Activity adaptations, modifications , adaptive equipment
- Cultural, language, education, religious, and spiritual considerations
- Special skills and strengths
- Recommendations or referrals
If you are looking to change your Activity Assessment to be more compatible with the MDS 3.0, then check out Recreation Therapy Consultants. They have a new Activity Assessment form available.
5) What exactly triggers activities in the MDS 3.0?
- Any 6 items for interview for activity preferences has the value of 4 (not important at all) or 5 (important, but cannot do or no choice) as indicated by any 6 of F00500A through F00500H is coded a 4 or 5.
- Any 6 items for staff assessment of activity preferences item L through T are not checked as indicated by any 6 of F0800L through F0800T are NOT checked.
- The Mood Interview reveals the resident has little interest or pleasure in doing things as indicated by: D0200A1=1.
- Staff assessment of resident mood suggests resident states little interest or pleasure in doing things as indicated by: D0500A1=1.
6) What is the difference between the Resident Assessment Protocols (RAPs) and the Care Area Assessment (CAAs)?
RAPS and CAAs are very similar in the respect that both:
- Review MDS and gathered data
- Involve decision-making and care planning
- Determine triggered care areas and assess further
- Include documentation in the medical record
The major difference between the RAPs and the CAAs is that there is no mandated assessment tool/ protocol like there was with the MDS 2.0 RAPs. Now facilities may choose to use CAA resources (Appendix C) and/or current standards of practice, evidence-based or expert-endorsed resources to conduct further assessment of triggered areas.
7) Do I have to care plan if the resident is alert and oriented and codes a 4 (not important) or 5 (important but can’t do, no choice) in the Activity Preferences Interview and triggers in activities?
One of the ways in which CAT number 10, Activities, will trigger is if the resident interview for activity preferences is coded with a total of six 4’s or 5’s. If the resident is alert/oriented and codes a 4 (not important at all), it just alerts us that we should look into it further. It could be that the resident is indeed alert/oriented, but is there some type of psychosocial factor or health issue that is the underlying cause of the resident answering a 4? Or is it that the resident answers 4's because he/she simply has no interest in those preferences being asked of him/her and may have other interests instead, such as crafts, exercise, computers, etc? Or if a resident codes a 5 (can’t do or no choice) this may indicate the resident has perceived or actual barriers or has developed a sense of learned helplessness. The primary concept of the CAA process is to look for those underlying causes and contributing factors.
The decision to care plan or not will vary depending on the CAA analysis and findings. It is also important to note that just because a resident triggers in activities, doesn’t mean we have to care plan for it. It is equally important to note, however, that just because a resident doesn’t trigger in activities, doesn’t mean we shouldn’t care plan. The decision to care plan or not is truly based on the resident’s problems, needs, preferences, strengths and the IDT’s findings and recommendations.
8) What do I do if the resident cannot or refuses to answer the interview questions?
If the resident doesn’t answer a preferences question, or answers with an incoherent or nonsensical response, then the assessor is to code a 9. Three code 9’s and the assessor is to stop the interview and complete the staff assessment for customary routine and activity preferences.
9) What type of documentation do I need to do for the CAAs?
CAA responsibilities, how it is facilitated, and where it is written in the medical record, will depend on facility protocol. Further assessment in a particular area should be within the scope of training or practice of the discipline filling out the section. CAA process must be interdisciplinary and involve the resident/significant other. CMS clearly states that CAA documentation must include:
- Nature of issue/condition.
- Causes, contributing risk factors, complications.
- Need for referrals and/ or further evaluation.
- Factors that must be considered in developing individualized care plan interventions including appropriate documentation to justify the decision to plan care or not to plan care for the individual resident.
- Resources used - Facilities may have written policies/ protocols/ standards of practice.
- Completion of Section V (CAA Summary).
10) Where can I watch the VIVE
11) We have a resident that is confused but she was able to answer the interview questions. Now I am having a conflict with Social Services. She said we shouldn’t interview when the resident is confused. Do you have advice or the right answer for me? Should we interview residents with confusion? I believe why not try. They still may be able to answer questions about their likes and dislikes. Any advice would help.
In terms of residents with cognitive impairment, the answer lies with the coding of B0700 (makes Self Understood) . If the resident codes a 0 (understood) ,1 (usually understood) or 2 (sometimes understood) , then you conduct the interview. If the resident codes a 3 (rarely/never understood), then you do not interview the resident-your next step is to attempt to interview the family or significant other.
12) Is Section F on the Quarterly?
Typically, section F is not on the Quarterly-however be sure to check with your facility and state regulators. Your state may have different rules. For example, I was recently informed that in the state of South Dakota they are required to complete the full item set for quarterly assessments. The CAA's, care planning, etc are not done, but the full item set is completed. So be sure to check your state regulations!
13) Since we no longer have to do a quarterly MDS for activities.. do you think we should still be doing a quarterly assessment on each resident or does a quarterly progress note suffice?
I would think a quarterly note would be ok-you'd identify if there were any changes in the note.
14) Section F interviews only need to be completed initially, annual and sig. changes? This is what I am being told. Since the RAI manual is so big can you maybe direct me to the page number or chapter as to where it says this?
It doesn't say in the RAI manual that sec F is only provided with the comprehensive assessment: admission, annual, sig change and sig change of prior correction. Believe me, it was the first thing I tried to find. It does say what a comprehensive assessment is and when that is offered (as indicated by the 4 times I just noted). I believe that is written in the assessment chapter of the RAI. Since section F is only shown to be on the comprehensive assessment, and not on quarterlies, PPS's and such, then this is a logical assumption. Although, I, like you, would like to see it officially written in the RAI manual.
15) Is there a place where we can direct questions directly to CMS to answer?
Questions regarding the "MDS 3.0 RAI Manual" should be directed to MDS30Comments@cms.hhs.gov. Please note that CMS will not be providing an individualized response to each inquiry; however, CMS will make sure the issues or comments are addressed in the upcoming MDS 3.0 training sessions or updates to the information provided on this page.
16) In the section F interview, what do I do with the blank boxes if the resident codes three "9"s and I skip to do the Staff Assessment? Do I leave the unasked questions blank?
No-you code a dash (-) in the unasked questions, otherwise it looks like you just didn't complete the section.
I know what triggers the CAA, but I don't know how to fill in the notes or how to fill in the explanation, its all very confusing for me.
Did you do the RAP's for the 2.0? If so, then the process is the same. Is your facility using the CAA Resources? If so, simply use the 4 page CAA Resources for activities and check off the areas that apply to the resident. Use that information gathered to write a narrative at the end of the CAA Resources describing why the resident triggered (or potential reasons).
If you are not using the actual CAA resources checklists that CMS provided, then use the CAA resources information to write your CAA summary. I love the CAA Resources checklist because it really makes you look at many possible reasons why the resident triggers for activities. Is it a health reason such as pneumonia? Is it because the resident is a short term stay and has no interest in activities? Is it a cognitive deficit, and so on. The point is to work through the CAA resources (or whatever additional assessment tool you have decided to use), to find out potential causes and reasons why the resident triggered. Residents typically trigger in activities because of some other reason-the underlying cause (mood, behavior, cognition, lack of resources, shyness, lack of interest, health reasons and dx, need for leisure education, medications, pain, availability, and so on. Use the CAA resources to help determine that underlying cause. Try it on one resident. Checking off each box in the left side of the CAA resource check list. In the right column write how you know that info. Was it in the medical record, or perhaps you observed it or a family or resident told you. It's a very helpful tool. It will also help you determine if you going to care plan or not.
Dear CMS, There has been much controversy and confusion over the "little pleasure or interest in doing things", found in section D0500 (A) and D0200 (A). The concern is with the word "things". This question is triggering activities quite often and there is major concern as to what the intent of the question is. If the term "things" does indeed refer to activities (recreational), then the question should be asked in such that manner. The resident should be made aware that the question refers to activities. I am assuming that things is referring to activities because of the relation to the answer has to triggering activities. On behalf of the Activity profession, I am asking you to please clarify the meaning of the term "things"? Thank you for your consideration. Kim Grandal, CTRS, ACC/EDU
Specific "things" are defined by the resident. They might be activities such as visiting others, drawing, reading, dancing, conversing with others, maybe the resident used to braid her grandaughter's hair when she visited and now she doesn't want to, etc. It may also refer to wanting to do "things" alone...so not necessarily activities with others. The question on the PHQ-9 cannot be rewritten to include the word "activities" as the PHQ-9 is validated and tested tool as it is currently displayed on the MDS 3.0.
Teresa M. Mota, RN, CALA MDS
Help Desk MDSQuestions@cms.hhs.gov
For more MDS 3.0 education, news and resources for Activity and Recreation Professionals visit http://www.recreativeresources.com/MDS3.0.htm