ALABAMA NURSING
HOME
QUALITY INITIATIVE
WALKING
IMPROVEMENT
Alabama Quality Assurance Foundation
Winter 2004
TABLE OF CONTENTS
TOPIC PAGE
Keys to Successful Walking Improvement Program ............................ 1
Ten Ideas from Alabama Nursing Homes for
Improving Walking Ability .................................................................. 2
Challenges to Walking Improvement Program .................................... 3
Walking Improvement Checklist .......................................................... 4
Overview: Walking Improvement ........................................................ 5
Summary of Key Elements to a Successful Walking
Improvement Program ........................................................................ 10
The Culture of Functional Mobility .................................................... 13
Walking Improvement: Essential Systems for Quality Care .............. 15
MDS RAI Coding Instructions ........................................................... 18
Federal Regulations: Guidance to Surveyors ..................................... 28
Alabama Quality Assurance Foundation
Winter 2004
KEYS TO SUCCESSFUL
WALKING IMPROVEMENT PROGRAM
FOR ALABAMA NURSING HOMES
To ensure a quality walking improvement program nursing facilities
need to consider incorporating the following into their programs.
On admission assess and document the functional
mobility status of the resident.
Determine the potential of walking improvement for
residents on admission or with change in status.
Develop goals consistent with residents’ needs and
capabilities.
Assess current medications that may affect balance or
ambulation potential and adjust or delete as needed.
Provide continual education and communication with the
resident and family or caregivers regarding status and
plan of care.
Implement and maintain the walking improvement
program on a daily basis.
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TEN IDEAS FROM ALABAMA NURSING HOMES
FOR IMPROVING WALKING ABILITY
The Alabama Quality Assurance Foundation (AQAF) has worked with Alabama Nursing
Homes since March 2003 on improving the walking ability of both post-acute and chronic
residents. These facilities have improved their quality measures related to walking
improvement in the post-acute resident by implementing some of the following interventions.
You may find one or more of these ideas helpful to your walking improvement program.
Use gait belts for all residents who require assistance with
transfers.
Start a walking program for long-term residents. One facility
called its program “Step It Up”. At specific times music is played
over the intercom. Staff members recognize that the music is a
signal to assist or encourage all residents to walk.
Get your residents to exercise. One nursing home used hoops and
batons as part of the exercise program. The residents decorated the
hoops and batons they used for the exercises.
Plant a garden and have the residents walk to and tend the garden.
Have physical therapy screen all new admissions.
Set up a system for therapy and nursing services to communicate
regularly, so that they are both working toward the same goals.
Make sure you have enough staff members to carry out needed
restorative programs.
Use creative scheduling so that restorative staff is scheduled on
evenings as well as days.
Make sure functional maintenance programs are reviewed by
restorative staff on a regular basis.
Encourage walking or assist resident to walk to all meals.
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CHALLENGES TO WALKING IMPROVEMENT
PROGRAM
In addition to coming up with wonderful ideas for improving the walking
ability of nursing home residents, we have identified some challenges or
barriers which you may want to avoid in putting together your programs to
improve walking ability.
Consider if your contract(s) for therapy services ensure all
residents are screened on admission.
Make sure staff document the components of your walking
improvement program and the data used to assess and improve the
program. This may ensure that disruptions to the program due to
staff turnover are minimized.
If CNAs have to document the ADL assistance they provide, based
on MDS terminology, make sure they understand this terminology.
Document the condition of newly admitted residents that are too
fragile to participate in therapy programs.
Make sure staff members evaluate residents on all shifts and get
input from therapy before coding section G of the MDS.
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WALKING IMPROVEMENT CHECKLIST
HOW DOES YOUR FACILITY MEASURE UP?
1. Does your facility have a process to screen for a resident’s potential for
walking improvement on admission?
2. How often are residents screened to determine their potential for walking
improvement?
3. Is there a process to communicate information from the results of the
screening to the rest of the staff?
4. Is there a process to communicate between therapy and nursing staff
regarding what nursing needs to be doing with the resident while the
resident is receiving therapy? Example: Nurses may walk the resident to
the bathroom.
5. Does your facility require staff, either CNAs or licensed staff, to
document the care given to residents based on the MDS terminology? If
so, do they understand this terminology?
6. Was information gathered from multiple sources prior to coding items
G1cA and G1dA? Example: staff over all shifts, chart and therapy input.
7. Does your facility have a process in place that evaluates whether nursing
documentation supports the coding of items G1cA and G1dA on the
MDS?
8. Does your facility have a policy and procedure for maintaining and
improving the walking ability of residents?
9. Are new employees educated on current specialized programs for
ambulation? Examples: park and walk, restorative programs, etc.
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OVERVIEW
WALKING IMPROVEMENT
Admission to a nursing home often coincides with older adults losing their independence
with mobility and becoming more dependent on assistive devices and/or wheelchairs. As
many as half of the nursing home residents who are wheelchair dependent have a history of
falls and up to 25% of residents who could walk were issued a wheelchair as a result of a fall
(Pawlson et al., 1986). It is also estimated that almost two-thirds of nursing home residents
require assistance with transfers and walking (Resnick, 1998). Immobility can be a serious
problem faced by nursing homes as it can cause limitations in activities of daily living, and
may lead to pressure ulcers, pneumonia, urinary stasis, constipation and fatigue (Norman &
Gibbs, 1991).
Causes of Decreased Ambulation
As older individuals become more physically or psychologically impaired their mobility
performance and skills tend to decrease. Further physical impairments such as loss of bone
and muscle mass can often occur as a result of decreased mobility, causing even less
mobility. Therefore, a spiral of functional decline begins.
Significant differences in biomechanical walking patterns are found between healthy older
and younger adults (Winter et al., 1990; Ferrandez et al., 1990). Older adults have:
A shorter step length;
Decreased velocity;
Increased double-support stance period (the stage of walking in which both feet are
touching the floor);
Decreased push-off power, a more flat-footed landing, and a reduction in their index of
dynamic balance.
Healthy younger adults typically perform ambulation at an energy efficient level while older
adults who are generally weaker and have decreased endurance have increased energy
expenditure during mobility tasks. Prosthetics, orthopedic impairments, weakened lower
extremities, and assistive devices can also add to the metabolic output needed with walking
(McGibbon et al., 2001; Annesley et al., 1990). Although the alterations in gait of older
adults indicate a progression toward a more safe, secure, and stable gait pattern, the cost of
energy output can be significant.
Risk factors for decreased ambulation and related falls can be categorized into two groups:
intrinsic and extrinsic. Intrinsic factors are those specific to the individual resident and
include:
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Advanced age;
Medication use (antidepressants, antihypertensives, and antipsychotics);
Chronic diseases (chronic obstructive pulmonary disorder, arthritis, congestive heart
disease, and Parkinson’s disease);
Daily alcohol consumption;
Impaired cognition;
Decreased visual acuity;
Incontinence;
Self-reported decline in health status;
Factors related to muscle strength, mobility, flexibility, cardiovascular conditioning and
balance; and/or
Additional factors may include falls resulting in fractures or fear of falling, decreased
endurance due to acute illness, infections, or psychological changes.
Extrinsic factors include:
Social issues such as living alone;
Personal factors such as level of risk-taking behaviors (Nowalk et al., 2001); and/or
Environmental hazards that pose risks for falls include: cluttered hallways or living
spaces, wet floors, presence of loose carpets or rugs, lack of grab bars, poor furniture
arrangement, and lack of adequate lighting (Jensen et al., 2002).
Motivation can have significant impact on a resident’s physical functioning. Resnick (1998)
suggests that residents who are motivated to improve had increased participation and
improved functional outcomes. The presence of depression was found to have a significant
correlation to a decline in functional abilities, however it may be because it has an impact on
motivation.
Barriers to Successful Walking Programs
Nursing departments are often understaffed resulting in individualized programs for residents
not carried out correctly or not addressed at all. Basic daily needs such as feeding,
medications, and toileting become the primary concern and there isn’t additional time to
address activities such as walking or exercise. When facilities are understaffed, caregivers
may assume it is more efficient to transport residents by wheelchair rather than supervised
walking. This may be realistic as an immediate solution; however over time, if the residents
were able to become independent ambulators the caregivers would spend less time
transporting residents within the facility.
High staff turnover rates can also be detrimental to existing programs designed for
individuals in nursing homes. New staff members are often not educated on individual
programs and can be unaware of their role in walking improvement. Therapy teams also
share this frustration as they work individually with the residents to gain progress and then
have concerns regarding the follow through and support that will be available after discharge.
Staff education and training must be very comprehensive during orientation, and must be
continual thereafter. Strong leadership and support must also be given to these programs by
supervisors and administrators.
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Benefits of Effective Walking Improvement Programs
Benefits from programs or interventions producing walking improvement include “increased
socialization, greater independence in functional areas, improved posture, balance,
coordination, cardiac conditioning, and relief from stress” (Norman & Gibbs, 1991).
“Progressive resistive strength training interventions can improve lower extremity strength,
balance, and performance in nursing home residents” (Resnick, 1998). Jivorec (1991) reports
multiple benefits identified in a literature review of various exercise regimens as: “increased
physical work capacity, increased muscle strength, improved aerobic capacity, increased
joint flexibility, improved body image, and increased life satisfaction”. Also, “increases in
range of motion and flexibility and decreases in recovery heart rate, aches, and pains”.
Psychologically, residents “demonstrated significant improvement in morale and attitude
toward their own aging” (Jivorec, 1991).
Research of Walking Improvement Programs
The majority of nursing homes offer exercise and walking programs for their residents, but
recent research shows that how the program is organized makes a big difference in resident
outcomes. Here are some ideas about how to make your program successful from a series of
studies that have improved outcomes for residents:
Program #1: The Functional Fitness for Long-Term Care (FFLTC) Program
The FFLTC (Lazowski et al., 1990) was designed not only to maintain upper and lower
extremity range of motion (ROM), but also to improve strength, balance, flexibility,
mobility, and function. It requires simple equipment and minimal training. Families,
volunteers, or nursing home staff can administer the program. Nursing home residents were
randomly assigned to 2 groups: ROM exercises only, or FFLTC. Each program was
conducted for 45 minutes, three times per week, for four months. Key components of the
FFLTC program included:
Progressive strengthening with resistive exercise bands and ankle/wrist weights;
Balance training with beanbags, balls, and balloons;
Flexibility exercises; and
Walking.
The FFLTC demonstrated greater functional outcomes than standard seated ROM exercise
programs and it can be individualized to the resident’s abilities. The program also has
additional benefits, as it can be safely implemented by nursing home staff, caregivers, or
volunteers with minimal education and low cost.
Program #2: A Six-Month Walking Program
Koroknay (1995) conducted a six-month walking program in order to promote functional
mobility in the frail nursing home population. Twenty residents who would not or could not
ambulate without the assistance of staff were identified based on initial assessments
completed by the nursing unit manager and the gerontological clinical nurse specialist
(GCNS). The goal was “to establish a nursing procedure that focuses on the resident’s need
to walk, and to improve or maintain the ambulatory status of the frail elderly… this goal was
accomplished by making walking a regular part of the day’s activities rather than an
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additional ‘task’, and by holding a nursing assistant accountable for walking residents”. Their
program included the following key points:
Nursing assistants assured that residents ambulated;
The focus was on maintaining mobility in frail nursing home residents who required
assistance with walking;
Schedules and goals were coordinated with the nursing unit’s activities (meals) and
the residents’ daily activities (using the restroom); and
The residents who were participants in the program experienced an increase in their
functional ambulation and a decrease in falls.
Staff was educated regarding the objective of the program, benefits of walking and exercise,
and the dangers of immobility. The environment was adapted to reflect banners and distance
markers for encouragement and motivation. New residents were assessed upon admission,
existing residents were continually reassessed, and goals revised if needed. Results of the
program reflected a significant improvement in ambulatory status, and the percentage of
residents who fell decreased from 25% to 5%. Koroknay also found that the residents with
cognitive impairments benefited as much as the residents who were cognitively intact.
Program #3: Functional Incidental Training (FIT)
The FIT program walking is integrated with prompted voiding (PV), which is a behavioral
intervention shown to decrease the severity of incontinence. Seventy-six residents
participated in the program for eight weeks. The subjects were randomly divided into two
groups, one integrated the FIT program with PV and the other was PV only. Every two hours
between 8:00 a.m. and 4:00 p.m. five days a week the residents were approached for toileting
needs. The subjects receiving the FIT protocol were encouraged to participate in transfers,
ambulation, and standing activities along with toileting assistance. The control group was
given socialization and toileting assistance. The FIT program was developed around three
principles:
(1) “The exercise should be integrated into the PV incontinence care routine”;
(2) “Emphasis should be placed on the repetition of exercises that are specific to the
functional skills involved with toileting and other activities of daily living”; and
(3) “The exercise should be designed both to gradually extend the resident’s exercise
tolerance and to be performed on a schedule that maximizes the efficient use of staff
time.”
Residents were given individualized goals for mobility and for standing tolerance. The
average walk time of ambulatory residents involved in the FIT program increased from 30
minutes a week to 55 minutes. The average sit to stands performed in a day improved from
3.4 to 10. The control group did not change significantly for either activity. Designing the
FIT program to be implemented by nurses aides while performing other care routines has the
advantage of time management as it only required an average of six minutes more per session
than the PV only.
Program #4: Walking Program
The residents walked five days a week for four weeks. The intervention lasted approximately
30 minutes per day and the residents were verbally encouraged to walk as far as they could
without taking a break. At the beginning of the study the subjects walked an average of 50
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feet before they were fatigued. After the study the residents walked an average of 73 feet.
Only two of the 15 subjects could rise independently out of a chair before the intervention
opposed to six after daily exercise. Three residents could walk unassisted before the program
compared to five at the end of the fourth week. The frequency of urinary incontinence was
significantly decreased during the day shift from an average of 2.33 incontinent episodes to
an average of one. The prevalence of urinary incontinence can be impacted by the
interventions of caregivers, and is related to muscle atrophy and loss of function such as
walking that often occurs in a nursing home setting (Jivorec, 1991).
Program #5: Walking Programs for Residents with Alzheimer’s Disease (AD)
One of the barriers identified by Tappen et al. (2000) of an effective ambulation program for
individuals with AD is compliance with the intervention. In their study, 65 residents with AD
were randomly assigned to treatment groups of assisted walking, walking combined with
conversation, and conversation-only. Interventions were provided for 30-minute intervals
three times a week for 16 weeks. Residents in the assisted walking group declined with
functional mobility by 20.9%, the conversation-only group declined by an average of 18.8%,
and the combined walking and conversation group declined only 2.5%. Residents in the
conversation-only group had a compliance rate of 90%, the combined group averaged 75%
compliance, and the ambulation only achieved a compliance rate of 57%. The conversation
element of the intervention appears to have improved compliance of the residents. Based on
the results of this study, Tappen et al. suggest that assisted walking with conversation can
contribute to maintenance of functional mobility, specifically ambulation, for individuals
with Alzheimer’s disease in nursing homes.
Program #6: A Walking Improvement Program
MacRae et al. (1996) conducted a 12-week walking program to determine the effects on walk
endurance capacity, physical activity level, mobility, and quality of life in ambulatory
nursing home residents who had been identified as having low physical activity levels and
low walk endurance capacities. The subjects were divided into two groups, a walking
program or a social program. The residents in the walking program ambulated five times a
week up to 30 minutes a day for 12 weeks. The control social group had individual social
visits for 30 minutes. The results showed significant progress. The subjects in the walking
program increased their maximal walk endurance time by 77%, and distance by 92%
(MacRae et al., 1996).
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SUMMARY OF KEY ELEMENTS TO A SUCCESSFUL WALKING
IMPROVEMENT PROGRAM
Many interventions for walking improvement have been initiated since the Omnibus Budget
Reconciliation Act (OBRA) of 1987, which emphasized the necessity for long-term care
facilities to maintain and promote higher levels of functioning. Programs require support by
the entire interdisciplinary team and are typically implemented by physicians, restorative
personnel, therapists, gerontological clinical nurse specialists, or nursing unit managers.
Responsibilities of the team should include:
Making initial assessments of functional mobility status
Determining the potential of walking improvement
Developing goals consistent with residents’ needs and capabilities
Assessing current medications that may affect balance or ambulation potential and
adjust or delete as needed
Providing continual education and communication with the resident and family or
caregivers regarding status and plan of care
Implementing and maintaining the program on a daily basis
Staff members must be aware of the goals, purpose, and design of the program in order to be
effective and accountable. The elements of successful treatment according to Tinetti (1986)
are: “correct exercise prescription, good supervision, continuity and persistence, and stepwise
progression”.
Norman and Gibbs (1991) also support a model of an interdisciplinary team approach. In this
model physical therapists make referrals to nursing for residents currently on therapy
caseload who could benefit from additional ambulation practice on the unit with supervision
by the nursing staff. Therapists provide education and training to the nursing staff regarding
the resident’s potential and functional skills, and provide gait and balance assessments to
measure baseline status and progress throughout the course of stay in the facility. Nursing
staff that recognizes a change in condition of the resident’s mobility status request an
evaluation by a physical therapist. The gerontological clinical nurse specialist offers initial
and reassessments for appropriateness of admission into the program, and medication
adjustments are made through collaboration with the physician. Volunteers assist by
providing incentives such as certificates or awards, and providing refreshments for the
program. Further responsibilities include environmental or maintenance personnel to help
with marking the distances in the hallways or environmental modifications, the activities
department to keep a record of progress in a main area with the resident’s consent, social
services to inform families and caregivers of the resident’s progress, and dietary to
recommend supplemental nutrition to increase energy.
According to Crotty (1999), one long-term care facility was able to turn their falls prevention
program into a best practice with individualizing the program according to their facility’s
needs. The quality improvement team reviewed residents’ records and identified all residents
at risk for falls, and tracked when the falls normally occurred. They determined the majority
of falls occurred between 11:00 a.m. - 3:00 p.m. The staffing schedule was adjusted and a
new position titled “Special Care C.N.A.” was created with the redistributed hours. This new
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position “concentrates on residents who require special attention at the busiest times of the
day with tasks such as showering, walking to events, or assistance with one-on-one
activities” (Crotty, 1999). In the following quarter the fall rate decreased by 15%. Additional
approaches included individualized prevention programs following changes in psychotropic
drug plan, and reviewing resident care plans during morning interdisciplinary meetings the
day after a fall. An interdisciplinary focus was important to ensure staff awareness to
residents at risk. Documentation of data such as time of fall, date, and injuries sustained, is
essential in identifying results of the program and areas of improvement.
Walking interventions should include components such as: strength and balance training,
endurance training, cardiovascular conditioning, and motivational persuasion. According to
Norman and Gibbs (1991) intervention strategies should involve reassurance, praise for
encouragement, verbal goal reminders, and incentives for participation. Residents should be
encouraged to set their own goals. The more control they have over their own progress the
more motivation and ownership they will exhibit throughout the program. Residents may
develop their treatment plan to include when they walk, how far, time of day, which route to
take and offer suggestions for the program (Norman & Gibbs, 1991). Determining underlying
causes of decreased mobility can also be an important aspect. Norman and Gibbs suggest
beginning by identifying residents who ambulate and do not use a wheelchair, those who are
unable to ambulate, and those who can ambulate but use a wheelchair. Pawlson et al. (1986)
interviewed 50 residents who used wheelchairs but could ambulate and found the three
reasons cited most often were fear of falling, they could get around faster, and they get too
tired when they walk; respectively. Further investigation from that point may assist in
reducing dependent mobility patterns.
Comprehensive programs involving rehabilitation and discharge from the facility to a lesser
level of care should include balance and gait training, walking on uneven surfaces, on
carpeted floors, negotiating stairs, maneuvering through obstacles, walking outside on
sidewalks using curbs, and practicing car transfers. The best opportunity to predict success in
the subsequent environment is to perform an on-site evaluation with the resident present. If
family members or other caregivers will be involved in the follow up care, it would be
helpful to have them attend for educational purposes. Further therapy provision by caregivers
or home health therapists may be needed once the resident is discharged from the facility to
assist the resident with achieving their highest possible level of independent ambulation.
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References
1. Annesley AL, Almada-Norfleet M, Arnall DA, Cornwall MW. Energy Expenditure of
Ambulation Using the Sure-Gait® Crutch and the Standard Axillary Crutch. Physical
Therapy. 1990; 70: 18-23.
2. Crotty MT. Setting Best Practices in Motion. Provider. 1999; 25(7): suppl 7,10.
3. Ferrandez AM, Pailhous J, Durup M. Slowness in Elderly Gait. Experimental Aging
Research. 1990; 16: 79-89.
4. Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and Injury Prevention in Older
People Living in Residential Care Facilities: A Cluster Randomized Trial. Annals of
Internal Medicine. 2002; 136: 733-741.
5. Jivorec MM. The Impact of Daily Exercise on the Mobility, Balance, and Urine Control
of Cognitively Impaired Nursing Home Residents. International Journal of Nursing
Studies. 1991; 28(2): 145-151.
6. Koroknay VJ, Werner P, Cohen-Mansfield J, Braun JV. Maintaining Ambulation in the
Frail Nursing Home Resident: A Nursing Administered Walking Program. Journal of
Gerontological Nursing. 1995; 21(11): 18-24.
7. Lazowski DA, Ecclestone NA, Myers AM, Paterson DH, Tudor-Locke C, Fitzgerald C,
Jones G, Shima N, Cunningham DA. A Randomized Outcome Evaluation of Group
Exercise Programs in Long-Term Care Institutions. Journal of Gerontology: Medical
Sciences. 1999; 54A(12): M621-M628.
8. MacRae PG, Asplund LA, Schnelle JF, Ouslander JG, Abrahamse A, Morris C. A
Walking Program for Nursing Home Residents: Effects on Walk Endurance, Physical
Activity, Mobility, and Quality of Life. Journal of the American Geriatrics Society. 1996;
44: 175-180.
McGibbon CA, Puniello MS, Krebs DE. Mechanical Energy Transfer During Gait in
Relation to Strength Impairment and Pathology in Elderly Women. Clinical
Biomechanics. 2001; 16(4): 324-33.
9. Norman G, Gibbs J. Why Walk When You Can Ride? Clinical Ambulation Incentives for
the Immobile Elderly. Journal of Gerontological Nursing. 1991; 17(8): 29-33.
10. Nowalk MP, Prendergast JM, Bayles CM, D’Amico FJ, Colvin GC. A Randomized Trial
of Exercise Programs Among Older Individuals Living in Two Long-Term Care
Facilities: The FallsFREE Program. Journal of the American Geriatrics Society. 2001;
49(7): 859-65
11. Pawlson G, Goodwin M, Keith K. Wheelchair Use by Ambulatory Nursing Home
Residents. Journal of the American Geriatrics Society. 1986; 34(12): 860-864.
12. Resnick B. Functional Performance of Older Adults in a Long-Term Care Setting.
Clinical Nursing Research. 1998; 7(3): 230-249.
13. Schnelle JF, MacRae PG, Ouslander JG, Simmons SF, Nitta M. Functional Incidental
Training, Mobility Performance, and Incontinence Care with Nursing Home Residents.
Journal of the American Geriatrics Society. 1995; 43: 1356-1362.
14. Tappen RM, Roach KE, Applegate EB, Stowell P. Effect of a Combined Walking and
Conversation Intervention on Functional Mobility of Nursing Home Residents with
Alzheimer Disease. Alzheimer Disease and Associated Disorders. 2000; 14(4): 196-201.
15. of the Tinetti ME. Performance-Oriented Assessment of Mobility Problems in Elderly
Patients. Journal American Geriatrics Society. 1986; 34(2): 119-126.
16. Winter DA, Patla AE, Frank JS, Walt SE. Biomechanical Walking Pattern Changes in the
Fit and Healthy Elderly. Physical Therapy. 1990; 70: 340-347.
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THE CULTURE OF FUNCTIONAL MOBILITY
In an integrated organization all staff and caregivers understand the basic issues of mobility,
strive to maximize the conditions that support mobility, and effectively communicate the
needs and approaches to meet that end.
Administrators
Understand the vision of good functional mobility
Oversee compliance with protocols to achieve that vision
Demand consistency and accountability in their execution
RNs and LPNs
Understand the vision of good functional mobility
Can perform impeccable bed mobility, transfers, and gait assistance, the
modifications thereof, and frequently demonstrates these to CNAs
Know well the specific mobility limitations and needs of their residents
Hold CNA's accountable for consistently performing the correct bed mobility,
transfers, and gait assistance for each resident
Stay in communication with CNA's about all mobility issues of residents during shift
change briefings
Promptly request rehab screens when declines and gains are detected
Objectively chart those changes prior to screen requests
CNA's
Are bed mobility, transfer, and gait assistance experts
Know when to slow down and how to integrate with the abilities and natural pace of
each resident
Know the particular mobility limitations and needs of each resident in their charge
Assist mobility in a manner that challenges the resident to use their full capacity and a
little bit more
Reinforce and train their colleagues and new CNA's in those needs and techniques
Dialog with their colleagues, nurses, and rehab staff sharing their insights and asking
questions
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Restorative Staff
Are bed mobility, transfer, and gait assistance experts in all manners as described
above
Are knowledgeable of and can execute the restorative protocols established by rehab
Identify and report changes to nursing and rehab detected during restorative
interventions
Communicate and reinforce good mobility practices to the nursing staff
PTs, OTs, and STs
Screen, evaluate, and treat new admissions, readmissions, and residents with
objective declines or gains in mobility, positioning, and speech performance
Provide specialized interventions in those areas
Design and implement restorative programs
Train staff in formal in-services, in patient specific caregiver education, and address
general mobility and speech concerns as they arise that are not patient specific, unless
that patient is currently on caseload with physician orders to treat (this is a grey area)
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Walking Improvement: Essential Systems for Quality Care
The following information suggests areas to focus on while evaluating facility processes for walking improvement
Systems to Review Key Interventions for Walking Improvement
Assessments
Develop systems to screen or evaluate walking based on illnesses, cognitive or sensory changes, gait or
balance disorders, alterations in continence, medications, or environmental factors.
Include prior level of function and medical necessity for skilled intervention in the initial walking assessment.
Utilize standardized assessments to evaluate the resident’s level of balance upon admission (e.g., Tinetti
Assessment Tool, Berg Balance Test).
Evaluate the resident’s gait and mobility using a standardized assessment for baseline purposes. For example:
Tinetti Assessment Tool, Timed Up & Go, ELGAM, or GARS.
Identify the resident’s precautions from surgical procedures upon admission that may prevent progress with
functional walking.
Assess strength and the musculoskeletal system upon admission and periodically throughout the resident’s stay
at the facility.
Rehabilitative Treatment &
Process
Implement a system for tracking and identifying residents appropriate for screening by the rehab department
(e.g., New admissions, change of condition, quarterly screens).
Provide prior level of walking function in the initial evaluation if the referral to therapy is for walking
improvement.
Formulate measurable, functional goals for ambulation on the initial evaluation and update as needed in
subsequent documentation.
Develop a system to ensure that the progress and functional status of the resident are consistently documented
between therapy, nursing, and other relevant disciplines.
Communicate the progress gained in therapy to ensure correct coding and accurate reflection of the resident’s
walking ability on the M.D.S.
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Conduct weekly or daily documentation of IDT meetings to discuss the resident’s progress/status with walking
(e.g., Medicare meetings or restorative meetings).
Formulate restorative programs, maintenance programs, and/or home exercise programs to ensure maintenance
or improvement of progress achieved during therapy.
Provide evidence of resident, family/caregiver, and/or facility caregiver education regarding level of
independence, programs, safety issues, and precautions throughout therapy and at discharge if needed.
Consider a “Walking Club” to include incentives, awards, and goals determined by individual residents.
Collaborate with Social Services or Discharge Planner regarding discharge planning, disposition, family
involvement, resident’s goals, and appropriateness of community resource involvement to ensure success after
discharge.
Staff Training & Education
Complete in-services at least quarterly to address all aspects of walking improvement.
Provide documentation that reflects staff training and understanding of roles and responsibilities of walking
improvement programs.
Track accountability regarding ambulation programs.
Educate employees regarding referrals to the rehabilitation department when a resident is exhibiting difficulty
with ambulation.
Train all caregivers on how to document each walking intervention including functional abilities, level of
independence, assistive devices, progress/decline in ambulation or change in condition, resident’s response to
walking, and distance and time walked.
Include education regarding gait, transfer training, gait belt utilization, assistive devices, precautions, and body
mechanics in employee orientation.
Inform all relevant caregivers on current specialized programs for ambulation (e.g., park and walk, restorative
programs, maintenance programs).
Review documentation and implementation of programs to ensure staff has been educated and understands
responsibilities.
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Restorative Treatment & Process
Assess resident’s fall risk upon admission and again with each fall or change in condition.
Execute restorative program according to recommended frequency and duration.
Problem solve with rehabilitation department if resident is unable to tolerate formulated program according to
the recommendations provided, or if the resident has a change in condition.
Implement a policy that allows for dedicated staff to the restorative department; provide cross training for all
C.N.A. staff on restorative treatments.
Interact with the rehabilitation department on a regular basis to review appropriateness of each resident’s
program on caseload.
Document each intervention including functional abilities, level of independence, assistive devices,
progress/decline in ambulation or change in condition, resident’s response to walking, and distance and time
walked.
Care Planning
Reflect a problem with ambulation on the Care Plan if the resident has had a recent decline with walking (e.g.,
gait deficits, Impaired mobility, Impaired balance).
Include appropriate short and/or long-term goals for walking improvement if a problem with ambulation was
identified on the resident’s Care Plan (e.g., Resident will improve ambulation from moderate assist to minimal
assist by 30 days with verbal cues and a front wheeled walker).
Use valid approaches for walking improvement in the intervention to increase ambulation skills (e.g., Balance
exercises and lower extremity strengthening).
Document the person(s) responsible for implementing and achieving the goal on the Care Plan.
Provide evidence that the Care Plan is updated as needed.
Ensure the relevant disciplines involved in facilitation of the Care Plan have documentation to support the
interventions and goal.
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MDS RAI CODING INSTRUCTIONS
G1. (A) Activities of Daily Living (ADL) Self-Performance
Intent: To record the resident’s self-care performance in activities of daily living (i.e.,
what the resident actually did for himself or herself and/or how much verbal or
physical help was required by staff members) during the last seven days.
Definition: ADL SELF-PERFORMANCE - Measures what the resident actually did (not
what he or she might be capable of doing) within each ADL category over the last
seven days according to a performance-based scale.
Walk in Room - How resident walks between locations in his/her room.
Walk in Corridor - How resident walks in corridor on unit.
Process: In order to be able to promote the highest level of functioning among residents,
clinical staff must first identify what the resident actually does for himself or
herself, noting when assistance is received and clarifying the types of assistance
provided (verbal cueing, physical support, etc.)
A resident’s ADL self-performance may vary from day to day, shift to shift, or
within shifts. There are many possible reasons for these variations, including
mood, medical condition, relationship issues (e.g., willing to perform for a nurse
assistant he or she likes), and medications. The responsibility of the person
completing the assessment, therefore, is to capture the total picture of the
resident’s ADL self-performance over the seven-day period, 24 hours a day - i.e.,
not only how the evaluating clinician sees the resident, but how the resident
performs on other shifts as well.
In order to accomplish this, it is necessary to gather information from multiple
sources - i.e., interviews/discussion with the resident and direct care staff on all
three shifts, including weekends and review of documentation used to
communicate with staff across shifts. Ask questions pertaining to all aspects of
the ADL activity definitions. For example, when discussing Bed Mobility with a
nurse assistant, be sure to inquire specifically how the resident moves to and from
a lying position, how the resident turns from side to side, and how the resident
positions himself or herself while in bed. A resident can be independent in one
aspect of Bed Mobility yet require extensive assistance in another aspect. Since
accurate coding is important as a basis for making decisions on the type and
amount of care to be provided, be sure to consider each activity definition fully.
The wording used in each coding option is intended to reflect real-world
situations where slight variations are common. Where variations occur, the
coding ensures that the resident is not assigned to an excessively independent or
dependent category. For example, by definition, codes 0, 1, 2, and 3 (Independent,
Supervision, Limited Assistance, and Extensive Assistance) permit one or two
exceptions for the provision of heavier care within the assessment period. While
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it is not necessary to know the actual number of times the activity occurred, it is
necessary to know whether or not the activity occurred three or more times within
the 7 days.
Because this section involves a two-part evaluation (Item G1A, ADL Self-
Performance and Item G1B, ADL Support), each using its own scale, it is
recommended that you complete the Self-Performance evaluation for all ADL
Self-Performance activities before beginning the ADL Support evaluation.
To evaluate a resident’s ADL Self-Performance, begin by reviewing the
documentation in the clinical record. Talk with clinical staff from each shift to
ascertain what the resident does for himself or herself in each ADL activity as
well as the type and level of staff assistance being provided. As previously noted,
be alert to differences in resident performance from shift to shift, and apply the
ADL codes that capture these differences. For example, a resident may be
independent in Toilet Use during daylight hours but receive non-weight bearing
physical assistance every evening. In this case, the resident would be coded as a
“2” (Limited Assistance) in Toilet Use.
The following chart provides general guidelines for recording accurate ADL Self-
Performance and ADL Support assessments.
Guidelines for Assessing ADL Self-Performance and ADL Support
The scales in Items G1A, and G1B, are used to record the resident’s actual level of involvement
in self-care and the type and amount of support actually received during the last seven days.
Do not record your assessment of the resident’s capacity for involvement in self-care - i.e., what
you believe the resident might be able to do for himself or herself based on demonstrated skills
or physical attributes. For nursing facilities, an assessment of potential capability is covered in
Item G8 (“ADL Functional Rehabilitation Potential).
Do not record the type and level of assistance that the resident “should” be receiving according
to the written plan of care. The type and level of assistance actually provided might be quite
different from what is indicated in the plan. Record what is actually happening.
Engage direct care staff, from all shifts, who have cared for the resident over the last seven days
in discussions regarding the resident’s ADL functional performance. Remind staff that the focus
is on the last seven days only. To clarify your own understanding and observations about each
ADL activity (bed mobility, locomotion, transfer, etc.), ask probing questions, beginning with
the general and proceeding to the more specific.
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Coding: For each ADL category, code the appropriate response for the resident’s actual
performance during the past seven days. Enter the code in column (A), labeled
“SELF-PERF.” Consider the resident’s performance during all shifts, as
functionality may vary. In the pages that follow two types of supplemental
instructional material are presented to assist you in learning how to use this code:
a schematic flow chart for scoring ADL Self Performance and a series of case
examples for each ADL.
In your evaluations, you will also need to consider the type of assistance known
as “set-up help” (e.g., comb, brush, toothbrush, toothpaste have been laid out at
the bathroom sink by the nurse assistant). Set-up help is recorded under ADL
Support Provided (Item G1B). But in evaluating the resident’s ADL Self-
Performance, include set-up help within the context of the “0” (Independent)
code. For example: If a resident grooms independently once grooming items are
set up for him, code “0” (Independent) in Personal Hygiene.
0. Independent - No help or staff oversight -OR- Staff help/oversight provided
only one or two times during the last seven days.
1. Supervision - Oversight, encouragement, or cueing provided three or more
times during last seven days -OR- Supervision (3 or more times) plus physical
assistance provided only one or two times during last seven days.
2. Limited Assistance - Resident highly involved in activity, received physical
help in guided maneuvering of limbs or other non weight-bearing assistance
on three or more occasions -OR- limited assistance (3 or more times) plus
more help provided only one or two times during last seven days.
3. Extensive Assistance - While the resident performed part of activity over last
seven days, help of following type(s) was provided three or more times:
Weight-bearing support provided three or more times;
Full staff performance of activity (3 or more times) during part (but
not all) of last seven days.
4. Total Dependence - Full staff performance of the activity during entire seven-
day period. Complete non-participation by the resident in all aspects of the
ADL definition.
For example: For a resident to be coded as totally dependent in eating, he or she
would be fed all food and liquids at all meals and snacks (including tube feeding
delivered totally by staff), and never initiate any subtask of eating (e.g., picking
up finger foods, giving self tube feeding or assisting with procedure) at any meal.
8. Activity Did Not Occur During the Entire 7-Day Period - Over the last seven
days, the ADL activity was not performed by the resident or staff. In other words,
the particular activity did not occur at all.
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For example: A resident who was restricted to bed for the entire seven-day
period and was never transferred from bed would be coded for both self-
performance and staff support as “8” since the activity (transfer) did not occur.
However, do not confuse a resident who is totally dependent in an ADL activity
(code 4 - Total Dependence) with the activity itself not occurring. For example:
Even a resident who receives tube feedings and no food or fluids by mouth is
engaged in eating (receiving nourishment), and must be evaluated under the
Eating category for his or her level of assistance in the process. A resident who is
highly involved in giving himself a tube feeding is not totally dependent and
should not be coded as “4”.
Clarification: Each of these ADL Self-Performance codes is exclusive; there is no overlap
between categories. Changing from one self-performance category to another
demands an increase or decrease in the number of times that help is provided.
Thus, to move from Independent to Supervision to Limited Assistance, non
weight-bearing supervision or physical assistance must increase from one or two
times up to three or more times during the last seven days.
There will be times when no one type or level of assistance is provided to the
resident 3 or more times during a 7-day period. However, the sum total of support
of various types will be provided 3 or more times. In this case, code for the least
dependent self-performance category where the resident received that level or
more dependent support 3 or more times during the 7-day period.
Examples
The resident received supervision for walking in the corridor on two occasions and non weight-
bearing assistance on two occasions. Code “1” for Supervision in Walking in Corridor.
Rationale: Supervision is the least dependent category.
The resident received supervision in dressing on one occasion, non weight-bearing assistance
(i.e., putting a hat on resident’s head) on two occasions, and weight-bearing assistance (i.e.,
lifting resident’s arm into a sleeve) on one occasion during the last 7 days. Code “2” for
Limited Assistance in Dressing.
Rationale: There were 3 episodes of physical assistance in the last 7 days: 2 non-weight-
bearing episodes, and 1 weight-bearing episode. Limited Assistance is the correct code because
it reflects the least dependent support category that encompasses 3 or more activities that were
at least at that level of support.
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SCORING ADL SELF PERFORMANCE
START
0 Frequency of
8
Does on own OR Activity never performed
Help
ACTIVITY DID
INDEPENDENT Aided 1 or 2 or By resident or other
times only a
NOT OCCUR
Supervision
Weight-Bearing
4
Full Staff
Assistance or Full
Performance TOTAL
Staff Performance
Every Time Over DEPENDENCE
7-Day Period
Non
Weight-Bearing
Physical
Assistance b 3
EXTENSIVE
ASSISTANCE
2
LIMITED
c Supervision ASSISTANCE
(oversight, cueing)
1
SUPERVISION
a) Can include one or two events where received supervision, non weight-bearing assistance, or
weight-bearing assistance
b) Can include one or two episodes of weight-bearing assistance, e.g., two events with non
weight-bearing assistance plus two of weight-bearing assistance would be coded as a “2”
c) Can include one or two episodes where physical help received, e.g., two episodes of
supervision, one of weight-bearing assistance and one of non weight-bearing assistance
would be coded as a “1”
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G1. (B) ADL Support Provided
Intent: To record the type and highest level of support the resident received in each ADL
activity over the last seven days.
Definitions:
a) ADL Support Provided: Measures the highest level of support provided
by staff over the last seven days, even if that level of support only occurred
once. This is a different scale, and is entirely separate from the ADL Self-
Performance assessment.
b) Set-Up Help: The type of help characterized by providing the resident
with articles, devices or preparation necessary for greater resident self-
performance in an activity. This can include giving or holding out an item that
the resident takes from the caregiver.
Process: For each ADL category, code the maximum amount of support the resident
received over the last seven days irrespective of frequency, and enter in the
“SUPPORT” column. Be sure your evaluation considers all nursing shifts, 24
hours per day, including weekends. Code independently of the resident’s Self-
Performance evaluation. For example, a resident could have been Independent in
ADL Self-Performance in Transfer but received a one-person physical assist one
or two times during the seven-day period. Therefore, the ADL Self-Performance
Coding for Transfer would be “0” (Independent), and the ADL Support coding
“2” (One person physical assist).
Coding: NOTE: The highest code of physical assistance in this category (other than the
“8” code) is a code of “3” not “4” as in Self-Performance.
0.No Setup or Physical Help from Staff
1.Setup Help Only - The resident is provided with materials or devices
necessary to perform the activity of daily living independently.
2.One Person Physical Assist
3.Two+ Persons Physical Assist
8. ADL Activity Itself Did Not Occur During the Entire 7 Days - When an
“8” code is entered for an ADL Support Provided category, enter an “8” code
for ADL Self-Performance in the same category.
For example: If a resident never left the unit during the assessment period, code
“8” for locomotion off unit. The activity did not occur, there was no help provided.
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Examples of Setup Help
For bed mobility - handing the resident the bar on a trapeze, staff applies ½ rails and then
provides no further help.
For transfer - giving the resident a transfer board or locking the wheels on a wheelchair
for safe transfer.
For locomotion:
Walking - handing the resident a walker or cane.
Wheeling - unlocking the brakes on the wheelchair or adjusting foot
pedals to facilitate foot motion while wheeling.
For dressing - retrieving clothes from closet and laying out on the resident’s bed; handing
the resident a shirt.
For eating - cutting meat and opening containers at meals; giving one food category at a
time.
For toilet use - handing the resident a bedpan or placing articles necessary for changing
ostomy appliance within reach.
For personal hygiene - providing a washbasin and grooming articles.
For bathing - placing bathing articles at tub side within the resident’s reach; handing the
resident a towel upon completion of bath.
Clarifications:
General supervision of a dining room is not the same as individual supervision
of a resident. If the resident ate independently, then MDS Item G1h is coded
as “0” (Independent). If the individual resident needed oversight,
encouragement, or cueing during the last 7 days, the item is coded as a “1”
(Supervision). For a resident who has received oversight, encouragement, or
cueing and also received more help, such as physical assistance provided one
or two times during the 7-day assessment period, the resident would still be
coded as a “1” (Supervision). Residents who are in “feeding” or “eating”
groups and who are individually supervised during the meal would be coded
as “1” (Supervision) for Self Performance in Eating.
The key to the differentiation between guided maneuvering and weight-
bearing assistance is determining who is supporting the weight of the
resident’s hand. If the staff member supports some of the weight of the
resident’s hand while helping the resident to eat (e.g., lifting a spoon or a cup
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to mouth), this is “weight-bearing” assistance for this activity. If the resident
can lift the utensil or cup, but staff assistance is needed to guide the resident’s
hand to his/her mouth, this is guided maneuvering.
If therapists are involved with the resident, their input should be included
either by way of an interview or by the assessor reviewing the therapy
documentation. The resident may perform differently in therapy than on the
unit. Also focus on occurrences of exceptions in the resident’s performance.
When discussing a resident’s ADL performance with a therapist, make sure
the therapist’s information can be expressed in MDS terminology.
CLARIFICATIONS USING THE CODE “8” (ACTIVITY DID NOT OCCUR)
If the resident is bed bound and does not walk and there was no locomotion via bed,
wheelchair or other means, then you would code an "8" for transfer and locomotion.
However, if the bed is moved in order to provide locomotion on or off the unit, then you
would code according to the definitions provided in Section G., 1A & B.
For example, use code 8 when the resident did not walk in the past seven days, (in room/in
corridor), for both the self-performance and the support columns.
A resident who has not been out of bed in the past seven days could be coded 8 for (A) & (B)
in MDS Sections G1b-f, unless the bed was moved (locomotion on/off unit). Other ADLs
are considered individually.
The eating item for G1h is a little more complex. If in the past seven days the resident truly
did not receive any nourishment, the item would be coded 8. It should go without saying that
this is a serious issue. Be careful not to confuse total dependence with eating (code 4) with
the activity itself (in this case, receiving nourishment and fluids). Keep in mind that a
resident who is fed via tube, and manages the tube feeding independently is coded as
independent (code 0). G1h includes receiving IV fluids. For a resident who is receiving
fluids for hydration, and is totally dependent, this is coded as 4, rather than 8.
Toilet use focuses on whether elimination occurs, rather than the process. The elimination
may be in the toilet room, commode, in the bedroom on a bedpan or urinal. It includes
transferring on/off the toilet, cleansing, changing pads, managing an ostomy or catheter and
clothing adjustment. The “8” code is rarely used in this section, as it would indicate that
elimination did not occur.
The examples that follow clarify coding for both Self-Performance and
Support. The answers appear to the right of the resident descriptions. Cover
the answers, read and score the example, then compare your answers with
those provided. For the purpose of this exercise the clinician should assume
that the resident has performed at the same level for the last 7 days.
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Self-
Examples: ADL Self-Performance and Support Perf. Support
Walk in room
Resident walked in his/her room while holding on to furniture for support. 0 0
Resident walked independently during the day and received non-weight 2 2
bearing physical help of 1 person for getting to the bathroom in room at
night.
Resident received non-weight bearing physical assistance of one person 2 2
for all walking in own room.
Resident did not walk but wheeled self independently in own room. 8 8
Walk in corridor
A timid, fearful resident is usually physically independent in walking.
During the last week she was very anxious and fearful of falling, and 1 0
therefore received reassurance and encouragement from someone walking
next to her while walking back to her room from meals in the unit dining
room.
A resident with memory loss ambulated independently on the unit corridor 1 1
albeit with a walker. Several times a day she left her walker in the
bathroom, in the dining room, etc., necessitating that someone return it to
her and offer her reminders to use it for safety.
Resident walked in corridor on unit by supporting self on one side with the 1 0
handrail along the wall and receiving verbal cues from another person.
Resident walked twice daily 4-6 feet in the corridor outside his room. He 3 2
received weight-bearing assistance of 1 person for each walk.
Resident walked in room for short distances with heavy assistance of 2 8 8
persons but traveled independently in corridor on unit by wheelchair.
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Self-
Examples: ADL Self-Performance and Support Perf. Support
Locomotion on unit
Resident ambulated slowly on unit pushing a wheelchair for support, 0 0
stopping to rest every 15 - 20 feet. She has good safety awareness and has
never fallen. Staff felt she was reliable enough to be on her own.
A resident with a history of falling and an unsteady gait always received 2 2
physical guidance (non-weight-bearing) of one person for all ambulation.
Two nights last week the resident was found in his bathroom after getting
out of bed and walking independently.
Resident ambulated independently around the unit “ad lib,” socializing 2 2
with others and attending activities during the day. Loves dancing and
yoga. Because she can become afraid at night, she received contact guard
of one person to walk her to the bathroom at least twice every night.
During last week resident was learning to walk short distances with new 3 3
leg prosthesis with heavy partial weight-bearing assistance of two persons.
He refuses to ride in a wheelchair.
Locomotion off unit
Resident independently walked with a cane to all meals in the Main 0 0
Dining Room (off the unit) and social and recreational activities in the
nearby hobby shop. Received no set-up or physical help during the
assessment period.
Resident walked independently to the off unit dining room for all meals. 0 2
For one visit to a clinic held at the opposite end of the building, she was
given a ride in a wheelchair by a volunteer. She was wheeled to the clinic
and after her session, she was wheeled back to her unit.
Resident is independent in walking about her residential unit. She does 1 0
get lost and has difficulty finding her room but enjoys stopping to chat
with others. Because she would get lost, she was always accompanied by
a staff member for her daily walks around the facility.
Resident did not leave the residential unit during the 7-day assessment 8 8
period
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FEDERAL REGULATIONS: GUIDANCE TO
SURVEYORS
Long-term care facilities participating in Medicare and Medicaid must meet certain federal
requirements necessary to assure the health and safety of individuals to whom services are
furnished. There are specific federal regulations related to the Quality Measures. This section
contains information, which is published by the Centers for Medicare, & Medicaid Services for
use in the long term care inspection process. The information included in this section is taken
from the federal regulations, guidance to surveyors, and survey protocols. These items are used
by state and federal regional office personnel to conduct surveys of long term care facilities for
compliance with the requirements at 42 CFR Part 483 Subpart B to receive payment under
Medicare or Medicaid. This information can be used by both facility, staff members and the state
survey agency in order to provide consistent quality care for the resident.
The federal regulations related to the Quality Measures can be categorized according to clinical
steps. There are federal regulations that govern assessment, care planning, and delivery of care.
Some of the Quality Measures are governed by federal regulations that are very specific to the
clinical issue. Other Quality Measures are addressed under federal regulations that are more
general in nature. This document provides an overview of pertinent regulations and the related
guidance to surveyors.
Guidance to surveyors, survey probes and procedures direct the surveyors in the evaluation of
care provided by the facility. Guidance to surveyors contains authoritative interpretations of
statutory and regulatory requirements and is used to make determinations about a provider’s
compliance with requirements. The guidance merely defines or explains the relevant statutes and
regulations and does not impose any additional requirement. Survey protocols, probes, and
procedures are different for each associated federal regulation. Some regulations have specific
“investigative protocols,” others do not.
When used with the Quality Measures, the regulations and the survey process become a powerful
tool for effecting changes in care systems that provide for improved delivery of care. Long-term
care providers must have a thorough knowledge of the federal requirements in order to comply
with the regulations and ultimately to provide for the health and safety of residents. An
understanding of the survey process will help providers evaluate the quality of care delivered and
target quality improvement efforts.
For regulations related to walking improvement please refer to the Guidance to
Surveyors-Long Term Care Facilities tags: F272, F279, F310, F311, F312.
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Disclaimer: The Alabama Quality Assurance Foundation (AQAF) provides this material to
healthcare providers with the understanding that it is for informational purposes only. The
Walking Improvement information does not take the place of a healthcare provider’s obligation
to use its own professional and clinical judgment. Healthcare providers that use the Walking
Improvement information agree to hold AQAF harmless from any damages that it or any third
party may incur, including but not limited to claims and damages to patients caused by use of the
Walking Improvement information. In the event that an action is brought by healthcare provider
or any third party against AQAF because of the Walking Improvement information or any
consequences associated with use of the Walking Improvement information, healthcare provider
agrees to fully indemnify AQAF against all costs and damages.
Acknowledgement: Material in this booklet was derived in part from information provided
by Rhode Island Quality Partners. Carole O’Hara, MS, PT and Jim Okel, MS, PT contributed to
various components of this booklet and their assistance is appreciated.
Alabama Quality Assurance Foundation
Two Perimeter Park South, Suite 200 West
Birmingham, AL. 35243
For further information or assistance with walking improvement contact:
Sue Boldin, RN, MSN, CPHQ
Quality Improvement Specialist
(800) 760-4550 ext. 3232
sboldin@alqio.sdps.org
Carol Hill, RN, CRNAC
Quality Improvement Specialist
(800) 760-4550 ext. 2284
chill@alqio.sdps.org
Or view the following websites:
AQAF website: www.aqaf.org
MEDQIC: www.medqic.org
This material was prepared by Alabama Quality Assurance Foundation under a contract with the Center for
Medicare & Medicaid Services (CMS). Contents do not necessarily represent CMS policy.
7SOW-AL-NHQI—03-24.