Document Sample
in Accuracy Review of Case-Mix Items

Residential Care Services Aging and Disability Services Administration October 2004


INTRODUCTION........................................................................................................................... 2 BACKGROUND INFORMATION................................................................................................ 3 GENERAL INFORMATON .......................................................................................................... 5 BEST PRACTICE INFORMATION .............................................................................................. 6 SECTION ―E‖ INFORMATION .................................................................................................... 8 SECTION ―G‖ INFORMATION.................................................................................................. 11 SECTION ―H3a‖ INFORMATION .............................................................................................. 14 SECTIONS ―P1‖ AND ―P3‖ INFORMATION............................................................................ 16 DOCUMENTATION GENERAL STATEMENT ....................................................................... 19 EXAMPLES OF DOCUMENTATION RELATED TO ......................................................... 20-39 NURSING REHAB/RESTORATIVE PROGRAMS



This document was first introduced in October of 1998. It provided Key Concepts, strategies and examples for ―best practice‖ in the accuracy review and documentation of case-mix items for MDS sections E, G, H3a, P1 and P3. Since that time, it has been distributed to not only Washington State nursing facility staff and Residential Care Services staff in Washington, but to many interested persons across the United States. There have been some changes and clarifications since 1998 and, in an effort to keep this a living, working document, it was updated in May, 2001. Because we live in an ever changing world and are continually learning, current processes have been modified, new policies and procedures developed and clarifications received that dictate a third update to this best practice document.

Note: This document is intended as guidelines for RCS (Residential Care Services) staff in the State of Washington during the process of MDS accuracy reviews. The guidelines should improve the consistent responses of RCS staff. This is also being shared with providers. There are helpful hints for providers enclosed within the document; these are not to be construed as federal or state requirements.

Revised October 2004


BACKGROUND INFORMATION  The RAI was developed first and foremost, as a comprehensive assessment tool to be used by clinicians in designing individualized care plans and programs for the residents they serve. Adherence to item definitions and the proper time period for observation of the resident’s status, as determined by the assessment reference date (A3a), is critical to ensure the accuracy and reliability of the assessment, and to provide a solid foundation for rendering care and evaluating the resident’s response to services.  To do this properly, clinicians must complete the MDS and utilize the RAPS according to the instructions provided by the Centers for Medicare and Medicaid Services (CMS) in the ―Revised Long Term Care Resident Assessment Instrument User’s Manual, Version 2.0‖ published December 2002 with additional updates in August, 2003, April 2004 and June, 2004. This manual, along with the MDS 2.0 forms, can be obtained at the following CMS website,  Since the advent of PPS for SNF Medicare services, there may have been a tendency for some facilities to creatively push the boundaries of MDS item definitions to maximize coding of particular MDS items, slide the resident into a higher RUG category, and thereby increase payment to the facility. This practice, if engaged in, will ultimately lead to problems. MDS data will increasingly be used within regulatory quality monitoring activities at both the state and national level. The accuracy of each facility’s MDS data will also be more closely scrutinized as CMS has implemented new MDS validation activities such as the DAVE program; Fiscal Intermediary Medical Review activities, and Program Safeguard activities, raising the risk that facilities who routinely push the bounds of MDS item definitions will be subject to citations and/or for civil fines for submission of inaccurate MDS data. Many providers have already come to the conclusion that the most efficient and practical way to complete the MDS is to do so using the ―clinical‖ rules put in place when the RAI system was originally implemented in 1990, and that the changes in practice required to ―game‖ the system are not worth the resulting remuneration in the short term. Adherence to the ―clinical‖ rules will provide an accurate picture of the resident, which should ensure that the facility receives a fair and equitable rate of reimbursement and is also evaluated fairly in activities that use MDS data to focus on regulatory quality

monitoring. Perhaps most importantly, accurate MDS coding is important for the benefit of the residents, as their care plans are derived from the MDS assessment.  The State of Washington does NOT have required formats or forms related to supporting documentation for the NF's MDS.  CMS revised the LTC RAI User’s Manual Version 2.0 in December 2002. Updates were issued in August 2003, April and June 2004.  CMS will continue to provide updates to the RAI Manual which will be posted on the CMS website.  Providers and Residential Care Services (RCS) staff will be notified of these revisions via ―Dear Provider‖ letters and Management Bulletins and will be expected to implement changes as directed by these updates.  Dear Provider letters written by RCS may also be sources of clarification of MDS issues, especially as they apply to Washington State.  The concepts in this document apply to all RCS staff QANs (Quality Assurance Nurse), surveyors, complaint nurses, etc. in reviewing the MDS for accuracy. What is acceptable during the QAN accuracy review needs to be consistent with RCS practice.  Key concepts:  Is the MDS response reasonable?  Is there clinical validity to the response?  Is there internal consistency within the MDS assessment?  Is there internal consistency within the medical record?  Is there internal consistency between the MDS and the medical record?


GENERAL INFORMATON  Stopwatches are not necessary or appropriate, and have never been considered (for RCS staff or for providers). However, the documentation of the amount of time that restorative/rehabilitative nursing programs are provided is required. This change occurred as a result of the revision to the RAI User’s Manual in December 2002. The format that the facility chooses for recording the time is up to the facility and there is great flexibility in how that can be accomplished.  Reviewing for the clinical relevance and validity of the program(s) for that resident continues to be a major focus. QANS should observe the program being delivered if there are any questions about the relevance or validity of the program.  If there is no evidence (through observations, interviews, internal consistency of the MDS and the record) to discredit or challenge the coded values, then accept them if they are reasonable and clinically valid. This process needs to make clinical sense.  During accuracy review visits, the QAN focuses on validating the MDS items that were transmitted to the CMS database managed by the state, that placed the resident into a particular RUG group. If care problems are observed, note them and put them aside for a follow up QA monitoring visit.  Visits for both the case mix accuracy review and QA monitoring may identify potential care problems. A focused review will provide further clarification of why a care outcome occurred and whether or not it was avoidable. Refer any concerns to the Field Manager for follow-up in the QAN protocol process.


BEST PRACTICE  The CMS Revised LTC RAI User’s Manual Version 2.0 December 2002 with updates in August 2003, April and June 2004 is the source document for coding the MDS. All previous Q&A documents published by CMS (formerly HCFA) and Washington State Q&A documents (1998 and 2001) have been rescinded.  Use information from your observations and interviews with the resident, staff and family (if available), as well as information from the clinical record when validating MDS accuracy. This is not a paper review.  Have all staff use MDS/RAP language (chart to the RAI)  Reduce duplication  Collect data for the assessment period only  Evaluate your documentation to ensure that MDS items used in the RUG-III classification system are supported in some other area of the record. If they are not, modify or supplement as needed  Make the RAI the core of your assessment, care planning and documentation system  Use processes you already have in place to tie things together  Ask yourself: Does the resident get the services he needs, and does he need the services he gets?  Once a good database has been established, providers can ―refer to‖ with appropriate modifications in future assessments.  Focus on the quality of the assessment (or reassessment), especially the analysis piece, rather than spending time rewriting something that is already documented in the record. Ask yourself if the interventions have accomplished what you intended them to, and if not, why not? Record the result of this discussion in the clinical record (record your clinical thinking).  If a facility chooses to utilize worksheets to collect assessment data, they may choose to limit the data collection to only the assessment period. This is perfectly acceptable, we do not expect to see them collecting data for 7 days


per week times 52 weeks per year! Requiring data collection to this degree is not an efficient practice.  If a facility utilizes worksheets to collect assessment data, such as an ADL flow sheet, and that data conflicts with the actual MDS coding, it is expected that there be some written explanation of ―why‖ the discrepancies exist in the clinical record.  If data gathering tools do not provide helpful information, either modify them or don’t use them. They are not required by either CMS or Washington State.  Key concepts:      Know the MDS definitions-use the RAI manual Use the RAI as the core to your assessment processes Analyze and use your data Review the clinical record for internal consistency Build viable nursing restorative programs


SECTION “E” INFORMATION In order to increase the consistency of QAN responses during the Case Mix Accuracy Review Process, the following are guidelines for the PROCESS OF REVIEWING THE ACCURACY of Section E. (Mood and Behavior Patterns). These guidelines for the PROCESS of review are not meant to replace or alter in any ways the RAI User’s Manual instructions for completing these sections. The guidelines below should be used in conjunction with the RAI Manual to ensure that a QAN’s judgment or conclusion on the accuracy of individual RUG items on a specific MDS would be consistent with another QAN’s judgment/conclusion about its accuracy. Specific worksheets completed by the facility staff for these sections during the A3a time period and the ―window‖ of time specified on the MDS are NOT a requirement. If the facility utilizes such worksheets, there is no requirement that the worksheets be kept and available for QAN review in the MDS Accuracy Review Process. The key concepts for the QAN are the ―reasonableness‖ of the facility’s coded response, the ―clinical validity‖ of the response, and the ―internal consistency‖ of the MDS assessment itself, the medical record itself, and the MDS assessment in relation to the medical record. As always, facilities are expected to comply with current medical record practices. The key expectations for facility documentation systems are that they focus on collection of supporting data in relationship to improving, maintaining, or minimizing decline in resident function. Clinical standards of practice often dictate the types and frequency of documentation.  Expect to find some collaborative data somewhere in the record that supports the coding (progress notes, RAP assessment, plan of care, social service assessments, etc.) If inaccuracies are apparent, or supporting data is not evident, VALIDATE this by talking with staff who know the resident. We may accept staff's rationale if it is reasonable, has clinical validity and/or it is consistent with other data from the MDS and the medical record.

 The RAI User’s Manual states that it is important to document chronic symptoms as well as new onset. The medical record should support resident status as reported on the MDS.


PROCESS FOR REVIEW OF SECTION E: MOOD AND BEHAVIOR PATTERNS  Scan the MDS, firmly fixing in mind the A3a time period. Note also the time periods reflected by the 30 day ―window‖ for Section E1; the 7 day ―window‖ for E2 and E4; and the 90 day (or since last assessment) reference for E3 and E5. Scan the care plan.  Utilize the Cognitive Performance Scale {B2a (short term memory), B4 (cognitive skills for daily decision making) and C4 (making self understood)} to assist in establishing the cognitive functioning of the resident.  Briefly observe the resident and their ―space‖ before completing an in depth record review. A brief social contact with the resident may set the stage for a more in depth interview later. This initial contact may assist in sorting through the enormous amount of data in a record while focusing on key relevant facts.  Review the 30 day ―window‖ in the progress notes, and the social services and activity progress notes (if kept separately), the social history as needed, the related mental health assessments and visits, and attendance and response in activity programs.  Review drug regimen for related drugs and behavioral/drug monitoring flow sheets for the specific time frame(s).  Look for care/treatment/food refusals on NAC flow sheets, in Restorative program flow sheets, meal monitoring, and specialized therapy.  If the resident is non-verbal, look especially for the E1 components that would still be applicable, such as E1j, k,l,m,n,o,and p.  When appropriate, ask the resident questions that might key into Section E. e.g. ―Has this been a difficult adjustment for you?‖ ―What has helped?‖ ―What could still be better‖. Etc.


 If Section E. is not done collaboratively (by a combination of disciplines), but completed by only one discipline, then check with staff who did NOT complete the section for validation of accuracy, e.g. If done by Social Services, ask Nursing.  Look for internal consistency of the MDS e.g. the relationship between the subsections of Section E; the relationship between B5(Indicators of Delirium) and Section E, etc.  Look for internal consistency of the medical record e.g. No major discrepancies or conflicting information found between or among different entries in the record, or between the various disciplines.  Expect to find some collaborative data somewhere in the record that supports coding in Section E. e.g. A single entry that clarifies the coding, or RAP data, etc.  If inaccuracies are apparent, or supporting data is not evident, VALIDATE this with staff. You may accept staff’s rationale if it is ―reasonable‖, has ―clinical validity‖ and/or it is consistent with other data from the MDS and the medical record.



In order to increase the consistency of QAN responses during the Case Mix Accuracy Review Process, the following are guidelines for the PROCESS OF REVIEWING THE ACCURACY of Section G. (Physical Functioning and Structural Problems). These guidelines for the PROCESS of review are not meant to replace or alter in any ways the RAI User’s Manual instructions for completing these sections. The guidelines below should be used in conjunction with the RAI Manual to ensure that a QAN’s judgment or conclusion on the accuracy of individual RUG items on a specific MDS would be consistent with another QAN’s judgment/conclusion about its accuracy Specific data gathering worksheets completed by the facility staff for these sections during the A3a time period and the ―window‖ of time specified on the MDS are NOT a requirement. If the facility utilizes such worksheets, there is no requirement that the worksheets be kept and available for QAN review in the MDS Accuracy Review Process. The key concepts for the QAN are the ―reasonableness‖ of the facility’s coded response, the ―clinical validity‖ of the response, and the ―internal consistency‖ of the MDS assessment itself, the medical record itself, and the MDS assessment in relation to the medical record. As always, facilities are expected to comply with current medical record practices. The key expectations for facility documentation systems are that they focus on collection of supporting data in relationship to improving, maintaining, or minimizing decline in resident function. Clinical standards of practice often dictate the type and frequency of documentation requirements.  Observe the resident performing at least 2 critical ADLs if there is any question regarding accuracy. Usually, eating and transferring will be the most meaningful and easiest to observe in order to validate all of the ADLs used in RUGs.


PROCESS FOR REVIEW OF SECTION “G” (PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMS) 1. Refer to explanations in Section E regarding worksheets, MDS ―windows‖. 2. Refer to Section E regarding Items # 1, #2, and #3 related to initial preparatory review, use of the Cognitive Performance Scale, and the initial brief observation/social interaction with the resident. This will facilitate review of Activity of Daily Living data. 3. Review care plan directives, RAP data, and/or quarterly summaries regarding ADL functioning. 4. When reviewing progress notes, note ADL references, even though outside of the 7 day ―window‖, as often there is no specific ADL references in the seven day period. It is likely that, barring a significant change or acute illness, the resident’s ADL status during the assessment period will mirror that referenced in earlier or even later record entries. Take note of any acute conditions, such as URI’s or UTI’s that might be present during the A3a time frames and significantly impact ―usual‖ performance. 5. Read comments sections on appropriate aide flow sheets (NAC’s, Activities, nursing rehab, etc.,) as they are often more meaningful or accurate than plus or minuses or initials after care directives. 6. Review RELATED Speech/OT/PT specialized (1:1) rehab assessments and notes looking for: 1) entry level, 2) consistency of performance, and 3)-exit level. 7. Make a judgment on the internal consistency of the record. If any inconsistencies are evident, validate these with the resident when able, and appropriate staff (Licensed staff and NACs). 8. Observe the resident performing at least 2 critical ADLs if there is any question regarding accuracy. Usually, eating and transferring will be the most meaningful and easiest to observe in order to validate all of the RUGS ADLs. 9. Avoid getting lost in the confusion of different terminology for ADL functioning used by Nursing staff and the Specialized Rehab. Staff. Whenever possible, encourage the use of the common language of the MDS. Ask the

facility for definitions, do not assume that your understanding is applicable to this facility’s practice. 10. Look for internal consistency of the P3 and the G sections, especially if all of the ADLs are coded as 4’s and/or if the Cognitive Performance Scale indicates that the resident would not be capable of ―new learning‖ and that new learning is an expectation of the restorative program. 11. If there is no evidence (observation, internal consistency of the MDS and the record) to discredit or challenge the coded values, then accept them if they are ―reasonable‖ and ―clinically valid‖. 12. Although there is no requirement to do the ADL Supplement (a worksheet located in the ADL RAP page C-28 of the MDS manual often helpful for Task Segmentation) re-familiarizing yourself with it may be helpful. If used, it may provide you with additional information for validation.


SECTION “H3a” INFORMATION  There are 3 key ideas related to H3a, Any Scheduled Toileting Plan/Program: 1) Scheduled—performing the activity according to a specific, routine time that is clearly communicated to all involved (resident and care givers) 2) Toileting—voiding (or having bowel elimination) in a bathroom or commode, or into another appropriate receptacle (i.e., bedpan or urinal for voiding). Check and change programs are not part of this definition and cannot be counted in H3a. 3) Program/Plan—a specific approach that is organized, planned, documented, monitored and evaluated.  Scheduled toileting programs could include taking the resident at scheduled times or verbally prompting the resident to go to the bathroom.  For residents on a scheduled toileting plan, the care plan should at least note that the resident is on a routine toileting schedule. A resident’s specific toileting schedule must be in place where it is clearly communicated, available to and easily accessible to all staff, including direct care staff. If the care plan is the resource used by staff to be made aware of the resident’s specific toileting schedules, then the toileting schedule should appear there.  Facility staff may list a resident’s toileting schedule by specific hours of the day or by timing of specific routines, such as ―upon rising, after meals, before bed, and PRN‖, as long as those routines occur around the same time each day. In most nursing facilities, the timing of such routines is fairly standardized. If that is not the case, then specific times should be noted.  Evidence of assessment for need of a program must be documented in the clinical record.  An evaluation of the resident’s response to the toileting program must be documented in the clinical record.

 H3a and H3b (Bladder Retraining Program) are considered as one of the Nursing Rehabilitative Programs for Case Mix purposes. These items must meet the criteria identified in the RAI User’s Manual on page 3-124 and 3-125, including meeting the definitions of ―program/plan‖.

 The criteria for Nursing Restorative/Rehabilitation programs (page 3-192 of the RAI User’s Manual) does not apply to these items and will not be used by QANs during accuracy review of these toileting programs.  It is also not necessary to document the time that these programs are being provided.


SECTIONS “P1” AND “P3” INFORMATION SECTION P – 1 (Special Treatments, Procedures, and Programs)  It is necessary to see documentation that would validate that the special treatment occurred. This could be the physician’s order and documentation that the order had been carried out, or it could be a follow – up telephone inquiry to the agency/facility that administered the treatment, and a signed notation of the information. Again, the QAN should consider the ―reasonableness‖, ―clinical validity‖ and ―internal consistency‖ of the specific issue.  The look back period for items P1a Treatments is 14 days. These treatments may have been provided to the resident at the facility, as a hospital out patient, or in-patient, or another setting. As long as the treatment occurred during the last 14 days, ―where‖ the resident received the treatment is not important.  Services that were provided solely in conjunction with a surgical procedure, and the immediate post-operative recovery period cannot be coded.  Adherence to the clarifications in the RAI User’s Manual is essential for accurate coding. There are coding exclusions that apply to several of the P1a items.



Nursing restorative/rehabilitation programs are nursing interventions that assist or promote the resident’s ability to attain or maintain his or her maximum functional potential. Additionally, the restorative/rehabilitative care should have identified objectives and approaches, and be supervised and evaluated by the nursing staff. The effectiveness of a program or the length of time a resident should be receiving restorative/rehabilitative care can only be determined on an individual basis.  Nursing restorative/rehabilitation programs must be based on an assessment for need and the results of that assessment should be documented in the clinical record.  In order to be coded on the MDS programs must meet all of the applicable criteria as listed in RAI User’s Manual on pages 3-192 and 3-194. Best Practice: Questions which should be asked regarding whether to initiate a program for a resident are: 1. Would the resident benefit from the program? 2. Will the restorative/rehabilitative care be of such benefit that routine nursing care would be unable to achieve the same goal? 3. Would the program assist in increasing the resident’s independence and self-worth? Best Practice: Regarding the length of time to keep a resident on restorative/rehabilitative care: 1. Has the resident attained his or her maximum potential? 2. If discharged from the program, would a decline in the resident’s functional level occur? Each resident must be considered individually and the best care for that resident, whether it includes restorative care or not, should be provided.  Look for internal consistency of the ―P3‖ and ―G‖ sections, especially if all the ADLs are coded as 4’s and/or if the Cognitive Performance Scale (CPS)

indicates the resident would not be capable of ―new learning‖ and new learning is an expectation of the program.  When reviewing nursing rehab programs, validate all programs identified for the resident. A red flag is if every ―P3‖ item is checked for 6 or 7 days a week.  In order for restorative/rehabilitative programs to be considered in the case-mix RUG classification system, the programs must be provided at least 6 of the 7 days during the assessment period. However, facilities should record the number of days the programs were provided even if less than 6 days.  Additional questions to ask: 1. Is it reasonable that this activity occurred for at least 15 minutes a day for the specified number of days during the assessment period? 2. Does the facility have sufficient staff to carry out the rehab/restorative program? 3. Are the plans individualized with reasonable time frames? 4. Which programs make clinical sense and will probably happen? Look for resident involvement in the program. 5. Was the program based on an assessment, with individualized interventions? 6. Is there an evaluation of the results/effectiveness of the program with resultant refinement of the interventions, if applicable, documented in the clinical record?



The MDS is a clinical assessment. As such, it is a primary source document and is considered part of the clinical record by federal regulation. It is, however, not a ―sole source‖ document. Documentation is currently federally required to substantiate coding of certain MDS items, as specified in the Revised Long Term Care Resident Assessment Instrument User’s Manual Version 2.0 December 2002. There is no federal requirement for a second source of documentation elsewhere in the record to substantiate the resident’s status for each and every MDS item. Information in the clinical record must support not conflict with the MDS. However, completion of the MDS does not obviate the facility’s responsibility to document a more detailed assessment of particular issues of relevance for the resident (e.g., as might be discovered through the RAPS, or by assessing areas not included or covered in sufficient depth on the MDS). Facilities are also required to document the resident’s care and response to care during the course of the stay, and it is expected that this documentation would chronicle, support and be consistent with the findings of each MDS assessment or quarterly review and related care issues. In addition, clinical documentation that contributes to identification and communication of residents’ problems, needs and strengths, that monitors their condition on an on-going basis, and that records treatment and response to treatment, is a matter of good clinical practice and is an expectation of trained and licensed health care professionals. There must be internal consistency within and between MDS items and written clinical record entries. Documentation is used to communicate information between team members related to incidents, care provided, treatments rendered and the resident’s general condition and response to living in the facility.


EXAMPLES OF DOCUMENTATION The following examples are intended to illustrate ways that facility documentation could be done in order to reflect the criteria required for nursing restorative/rehabilitative programs, as noted in the CMS RAI User’s Manual pages 3-124 through 3-125 for H3a and H3b programs and 3-192 through 3-195 for P3 programs. These are but one method to convey the needed information. Facilities may document in any form or format that they choose. Each example uses the same format. The MDS item illustrated is identified followed by the plan of care that includes the problem statement, goal(s) and then the specific interventions. The last item documented is the LN evaluation. We have attempted to provide examples using more than one style. A newer approach is the ―first person‖ style where the resident is directing care needed from their perspective. It is resident not care giver centered. Several facilities have begun using this approach in their plans of care and subsequent evaluations; the examples are included to demonstrate that fact. SECTION: H 3a (Any Scheduled Toileting Plan) RESIDENT #1 PROBLEM: Toilet use deficit related to impaired mobility secondary to CVA with mild left hemiparesis and osteoporosis. Also r/t cognitive deficit secondary to dementia (Alzheimer’s type vs. Multi – infarct) GOAL: Make toilet needs known; be free of peri – rash; be continent of bowels. INTERVENTIONS:  Toilet resident on request during waking hours, second/fourth rounds. During night assist with positioning during second/fourth rounds.  Allow resident to sleep first and third rounds.  Assist to toilet as needed during waking hours; bedpan during night.  Transfer with one-person assist.  Cue resident verbally to grab onto bar.  Cue resident to pivot then sit down.  Give resident privacy and remind her to use the call light when she is finished.

 Assist to clean perineum after toilet use and after each incontinence.  Assist resident with brief during waking hours.  Cue resident to grab onto bar to assist to a standing position, pull up resident pants, adjust clothing.  Give praise and reassurance. EVALUATION: Resident is frequently incontinent of urine, but does void on toilet/bedpan at times. Incontinence type assessed and appears to be a combination of urge and functional incontinence. Resident states that she feels the urge to void but most of the time is unable to stop the flow long enough to make it to the toilet. Resident in NRS (Nursing Restorative Service) for toilet use. Program reviewed. Goal changed to maintain bowel continence. Wears adult briefs which staff assist to put on. Pericare/incontinence care managed by staff. Resident is assisted to toilet on request during waking hours and assisted with bedpan on second and fourth rounds at night. Medications are ascorbic acid 500 mg PO bid and hydrochlorothiazide 12.5 mg qd. See section ―Cognitive Loss‖ for labs. Continue plan of care. Note: The above example was taken with permission from CHRISTA Senior Community. Subsequent evaluation of the H3a or H3b NRS could be documented in summary style of the above, but should include resident response to the program and modifications as appropriate. The following care plan and evaluation example is written using a “first person” style where the resident is directing care needed from their perspective. RESIDENT #2 Mrs. ―B‖ PROBLEM: I have a diagnosis, among others, of CVA with right hemi-Paresis. I am frequently incontinent of bladder. I am on Lasix which contributes to my incontinence but is necessary for my congestive heart failure. I am also occasionally incontinent of bowel if I don’t get to the bathroom on time. I do know when I need to go to the bathroom.


GOALS: My goal is not to have any urinary tract infections or constipation and to be able to continue to do my own toileting with cueing and assistance. I want to maintain my ability to use the bathroom and be as free from incontinent episodes as possible. INTERVENTIONS:  I do like to wear briefs at all times  I need one person assist to go to the bathroom at times and with peri care  Remind me to use the toilet upon awakening and before and after each meal and at bedtime  I usually have a bowel movement shortly after eating, especially after breakfast, so please make it a priority to assist me to the bathroom immediately after breakfast and after other meal times if I indicate the need. (this new intervention was added after the last evaluation)  Nursing staff need to document the number of times Mrs. ―B‖ is wet and the number of times she has had a bowel accident each shift EVALUATION: Mrs. ―B‖ has had 15 episodes of bowel incontinence the month of August with all occurring on the day shift. Since it was identified that she has a BM shortly after eating, particularly after breakfast, will change the care plan and do staff in-service around the new intervention to take her to the bathroom immediately after meals as a priority. She has had incidences of bladder incontinence several times a day this past month, occurring on all 3 shifts. Staff in-service held to impress to staff the importance of accommodating resident needs and to do priority toileting. Note: Adapted from care plan and restorative program from Hillcrest Manor. Used with permission



In the P - 3 Section, there are two main themes: 1. Planned, scheduled, and documented. 2. Improve or maintain the resident’s self - performance.

P3-a (Range of Motion Passive) RESIDENT #1 PROBLEM: Resident at risk for upper extremity contractures secondary to dementia, resistive to care, decrease in voluntary movement. GOAL: Resident will maintain full ROM to all joints of both upper extremities. INTERVENTION:  PROM R. & L shoulder, wrist, and fingers/ 10 REPS AM & PM daily (10 minutes per session)  Do not exceed point of pain. Resident responds best if her extremity is stroked gently to relax the muscles prior to initiating the ROM activity.  Extend all joints with a slow /gentle movement.  Speak gently to resident when providing care to assist resident to relax and cooperate.  Provide quiet environment to decrease external stimuli.  Do not attempt ROM when resident is agitated or resistive to care.... Reapproach after 15 minutes. EVALUATION: The resident permitted PROM 95% of the time this quarter and 7 days during the assessment period. Resident does not appear to experience pain during treatment, but is resistive when she is agitated. The resident requires a quiet environment and time spent relaxing her prior to beginning the treatment in order to decrease these behaviors. The preparation for this treatment frequently requires 5 to 10 minutes, with actual range taking a minimum of 10 minutes per session. The resident has had some changes to her anti-psychotic medications this quarter, which caused an increase in agitation and resistive behaviors. During this time, the resident needed to be re-approached as often as 5-6 times throughout the day. The


resident continues with full range of motion to all joints of both upper extremities (see RA quarterly assessment). Continue as planned.

RESIDENT#2 PROBLEM: Resident admitted with contractures to lower and upper extremities secondary to Parkinson’s disease and immobility. GOAL: Avoid increase in lower and upper extremity contractures per baseline measurements (see PT assessment) INTERVENTION:  PROM to all upper and lower extremities 5 REPS 6 days /week, approximately 15 minutes per session.  Do not exceed point of pain.  Use slow gentle movements when extending all joints.  Check for skin breakdown in creases of hand, elbow, axillary, popliteal and groin areas. EVALUATION: PROM provided as planned 6 days per week (see RA flow sheet). The resident’s joints are tight and very slow extension of these joints is necessary to prevent pain. It often takes 20 minutes to complete the exercises due to resident fear of pain and stiffness. There has been a minimal decline in ROM to elbows and knees (see RA quarterly assessment). The decline is due to increase in Parkinson disease process. PROM REPS to all extremities have been increased to 10/day to prevent further decline beginning tomorrow. PT. evaluation request from physician...declined (see physician progress notes dated 6/2/98). P3-b. (Range of Motion Active) RESIDENT#1 PROBLEM: Contractures of fingers, bilaterally, secondary to arthritis and immobility. GOAL: Participate in activities that provide AROM to fingers to minimize further contractures.

INTERVENTIONS:  Therapeutic exercise class (i.e., puzzles, cards, bread making. etc. 30 minute class). Mon., Wed. and Fri. Letter/ card writing, sorting and distribution Tues. and Thurs.  Licensed nurse will evaluate the resident before and during activity for energy level, SOB, and pain.  When necessary, re-enforce to resident the possible deleterious effects of over activity.  Cue for active ROM to fingers, wrists and shoulders 10 reps/ joint AM & PM resident will tolerate. (10 minutes per session) EVALUATION: Resident has moderate loss of mobility to her fingers and wrists due to arthritis. Her COPD and pain with arthritis has allowed sporadic participation in the AROM activities planned during this quarter (see activities and RA flow sheet). A recent change in her arthritis medication has allowed for an increase in activity. The resident is a very caring individual who likes to be as active as her disease processes allow. The resident has requested to participate in assisting other residents. Writing, sorting and distributing cards/letters assists in meeting the resident’s need to assist others, plus provides AROM to her extremities. The resident is resistive to the ROM REPS and needs lots of encouragement. She does not enjoy participation in ―physical exercise‖ for the purpose of ―exercising‖. She will, however, participate in other forms of activities (i.e., cards, bingo etc.) which provide AROM. The resident is committed to not letting her disease get the best of her, and will push herself to do more. Prior to participation in any of the activities (other than REPS), a licensed nurse evaluates the level of activity appropriate for her. When the resident insists on participation in an activity during times of SOB, the nurse consistently addresses the need to set limits, with the resident. The nurse, also, frequently checks the resident through - out the time of these activities. In addition, the resident frequently requires med. for pain prior to the participation in any ROM / REPS. The resident has maintained her previous level for ROM to all extremities.


RESIDENT#2 PROBLEM: At risk for contractures due to decreased mobility secondary to an implant of left knee prosthesis. GOAL: Maintain full ROM in all joints. INTERVENTIONS:  AROM to left ankle, knee and hip/ 10 REPS per joint / daily (15 minutes per session). See PT treatment plan for directions.  Do not exceed level of pain.  Evaluate resident’s level of activity prior to beginning exercise (over activity may cause muscle cramps).  Notify nurse of complaints of pain associated with ROM activity. EVALUATION: The resident has actively participated in all AROM activities this quarter, including all 7 days of the assessment period. The resident has recently experienced cramping of the L. hip with active range of motion. When the pain began the resident became fearful of movement of the affected extremity and required much cueing and encouragement to participate in AROM activities. These cramps appeared to occur when the resident had been particularly active prior to his AROM activity. The frequency of the pain increased as the resident became more mobile. The doctor was notified and he indicated these were muscle spasms. A muscle relaxant was ordered and its use has decreased the incidents of pain. The RA needs to evaluate the resident’s previous activities before starting the AROM avoid discomfort associated with over activity. The resident wears a knee brace and requires assistance to remove the brace, do the ROM exercise, and re-apply the brace. Removing and re – applying the brace can consume 5 to 10 minutes in addition to the actual AROM reps. The residents has maintained full range of motion in all joints this quarter (see RA quarterly assessment). Continue as planned.


P3 - c (Splint or brace assistance) RESIDENT#1 PROBLEM: Contractures of left arm /hand secondary to CVA. Left hand is painful at beginning of range of motion. Edema is noted to the left hand. GOAL: Prevent further contractures while maintaining current range. Keep skin intact. Minimal edema. INTERVENTIONS:  Hand care program.  Left arm and hand splints to be worn when up. Off when in bed.  Explain the range of motion to the resident before beginning. Provide pain medication 30 minutes prior to beginning program.  Gently and slowly do passive range of motion to the hand and arm.  Keep the left arm and hand elevated on a pillow.  Monitor skin before and after splint application.  Passive ROM to each joint in left hand and arm with 5 repetitions. EVALUATION: Range of motion to the left arm and hand remain the same. Resident compliant with the splint program. Splint applied 2x/day and removed 2x/day. ROM done 2x/day. Skin intact. Edema, when present, is no more than 1+. Elevation on a pillow has been helpful. Hand less painful during ROM when medication is given and the left hand is soaked in warm soapy water prior to ranging. Program takes 25 minutes per day (see RA flow sheet). Notes: Also, see RAI manual, Sec. P pg. 3 - 196, first example.

RESIDENT #2 PROBLEM: Requires a brace to right leg secondary to post polio syndrome. Alzheimer’s (Stage 5). GOAL: Resident will apply, remove and maintain brace with staff cues.


INTERVENTIONS:  Inspect skin of right leg prior to application of brace for s/s of irritation or pressure areas, breaks in the skin, ulceration, rashes, etc.  Resident to apply brace in am with verbal cues and demonstration.  Check with resident later to determine comfort of brace.  Cue resident to remove brace and clean as necessary at bedtime.  Inspect for skin integrity and report to licensed nurse any signs of redness, pressure marks or complaints from the resident regarding the fit. EVALUATION: Resident compliant with instructions/cues when given one at a time and each step completed before further instructions are given. Becomes somewhat belligerent when hurried through task. Will add interventions r/t clear one step direction and to do in an unhurried manner. Removing and maintaining brace in the evening usually exceeds 10 minutes, applying brace in the morning takes 5 to 10 minutes (see flow sheet for exact minutes per day). P3 - d (Training and skill practice in bed mobility) RESIDENT #1 PROBLEM: Impaired mobility when turning side to side in bed, related to Parkinson’s Disease. GOAL: Resident, with one-person assist, will grab hold of side rail to assist with turning in bed. Will be able to pull self part way over when being turned. INTERVENTIONS:  One person assist with turning  Give verbal cues for resident to grab side rail on the side to which he is being turned.  Encourage the resident to pull himself part of the way.  Turn every 2 - 3 hours. Note: Resident has painful left hip and can not tolerate more than 1-½ hours on left side. EVALUATION: Resident continues to be able to grab the side rail and pull self toward the desired side. Continues to need one person assist for positioning. Resident has less complaints of pain when turned off the left side in less than 1 ½ hours. Program

takes up to 8 minutes at times when resident is turned, resident is repositioned a minimum of 3 times per shift. Note: Also, see RAI Manual pg3-196 example #2. P3 - e (Training & skill practice in transfer) RESIDENT #1 PROBLEM: Weakness of right side secondary to Left CVA GOAL: Will bear weight on both legs and pivot on left leg to transfer with SBA INTERVENTIONS:  Remind resident to transfer from left side of bed.  Cue resident to hold onto trapeze with left hand and pull self to sitting position on side of bed.  Staff will lock wheel chair per resident instructions. If resident forgets, remind him.  Resident will stand on both legs, reach for left wheelchair arm and pivot transfer into wheelchair.  Lightly touch right leg if resident neglects to stand on it.  Position foot pedals within resident’s reach. Remind resident to put them on wheelchair with left hand.  Provide verbal encouragement.  Praise efforts. EVALUATION: Resident continues to need instructions to stand on both legs. He neglects his right leg, but will stand on it if leg is lightly touched. Resident naps in bed in a.m. and after lunch. Does not attempt to transfer independently at this time. He continues to need cues and assurance from staff during transfers. Each transfer session takes approximately 5 minutes and resident transfers a minimum of 6 times daily.

RESIDENT #2 PROBLEM: Weakness and instability of lower extremities secondary to Multiple Sclerosis. Dementia.


GOAL: Resident will bear weight on both legs during all transfers INTERVENTIONS:  Resident to bear weight on both legs during all transfers.  Two-person assistance when transferring resident.  Use gait belt.  Give step by step cues to put each foot on floor EVALUATION: Resident attempts to lift legs up when transferred. Needs step-by-step cues to put each foot down on floor before standing and pivoting into chair. Resident naps in bed in a.m. and afternoon, but enjoys sitting in chair at bedside when not in bed, dining room or activities room. Transfers take 5-8 minutes per session and occur approximately 4 times per day. P3 - f (Training and skill practice in walking) RESIDENT #1 PROBLEM: Slow unsteady gait related to MVA GOAL: Resident will walk to and from dining room for breakfast and dinner every day with use of quad cane and SBA. INTERVENTIONS:  Leave wheel chair in room.  Hand resident quad cane and walk with him to dining room.  Allow resident to rest in chairs in hallway, if he becomes tired.  Encourage resident along the way. EVALUATION: Goal achieved this quarter, which is an improvement from last quarter. Will increase ambulating to dining room to also include lunch with SBA. Long term goal is independent ambulating. (See RA flow sheet for number of minutes and days program provided)


RESIDENT #2 PROBLEM: Mobility impaired related to blindness, potential weakness secondary to DJD/Osteoarthritis GOAL: To maintain increased independent motion as evidenced by ambulating independently with walker to and from UDR (Upper Dining Room) and bathroom with verbal and manual cues.

INTERVENTIONS:  Allow resident adequate amount of time to get self-ready; do not rush resident.  Ask resident when she will be ready to walk to the UDR for meals, and go back to resident’s room at specified time of request.  Set up walker in front of resident to aid in assisting resident to a standing position.  Stand along side resident to provide verbal and manual cues for guidance while ambulating i.e. alignment of extremities, pacing, and proper positioning of walker.  Alert resident to obstacles and remove any clutter that may cause potential falls.  Encourage and allow as much independence as resident can manage safely.  Encourage resident to participate in daily exercises at gym, preferably 6x/week.  Report to LN if resident unable to participate in ambulating i.e. report a decrease in function, strength, endurance, or distance able to ambulate. EVALUATION: Resident continues to participate in an ambulation program. Goal continues to be met 100%. Resident continues to walk to and from UDR for meals as well as walking to the bathroom independently with verbal and manual cueing. The ambulation to the UDR takes about 10 minutes each way and resident eats all 3 meals in the UDR. Staff continues to alert resident of obstacles while walking along side resident with verbal cueing. Staff continues to encourage resident during ambulation and remind resident to count her steps from the UDR to her room. Room furniture is kept in set position for resident to serve as markers in letting her know where she is in the room. Ambulation program continues to be beneficial for resident

secondary to blindness. Staff work together with resident to maintain maximum potential for resident with walking and encourage resident to maintain as much independence as resident can manage safely. Note: Adapted from a CRISTA Senior Community plan of care. Used with permission. P3 - g. (Dressing & Grooming) RESIDENT #1 PROBLEM: Impaired ability to dress/groom self related to left hemiparesis and cognitive deficits. GOAL: Resident will maintain ability to dress and groom upper body with cues and one-person minimum assistance. INTERVENTIONS: Dressing:  Resident to choose between 2 articles of clothing for upper body.  NAC to place garment over head (if applicable).  Cue resident to raise the left arm with the right hand.  NAC assist with placing left arm in sleeve.  Cue to insert right arm into sleeve.  Cue to button garment and assist as needed.  Preparing for bed: repeat program in reverse  Grooming:  In AM, moisten wash cloth and place in resident’s right hand.  Cue to wash eyes and then remainder of face.  Allow resident to choose make-up and jewelry and assist as needed.  Document and report to nursing any refusals or difficulty with approaches as outlined above. EVALUATION: (Quarterly Review) Continues to participate in AM & PM dressing and AM grooming activities with cues and minimal assist. Chooses clothing for upper body and jewelry to wear daily. Refuses application of make-up routinely but will continue to offer assistance per resident request. Dressing activities take approximately 15 minutes each session with grooming activities 5-10 minutes depending on whether or not make-up is applied (See RA flow sheet for daily participation and time).

RESIDENT #2 This resident is a transfer from the swing bed section of the facility. When admitted he was weak with pitting edema of the lower extremities. Currently with a diagnosis of CHF and oxygen dependent with edema resolved. PROBLEM: Potential for decline secondary to being unmotivated to perform tasks. Resident prefers to let staff ―wait on him‖. GOAL: Will wash own hands and face, shave and comb hair after set-up; assist with dressing upper body within the next 60 days. INTERVENTIONS:  Explain procedures and expectations prior to beginning cares.  In AM and HS place grooming and hygiene items where he can reach them.  Resident wears dentures, glasses, hearing aid: staff to clean and hand to him for placement.  Verbally cue resident to put shirt on/off over head and arms in/out of shirt.  Cue him to lift legs to assist staff in dressing/undressing lower body.  Cue him to stand and pull pants up, fasten and zip.  Do not rush resident, if appears short of breath, stop and provide rest period.  Provide positive reinforcement for all attempts. EVALUATION: Resident has maintained the ability to assist with dressing/grooming of putting shirt on/off, washing hands and face, starting to shave (often finished by staff) and combing the front part of his hair during the past quarter, including the assessment reference period. He continues to lift legs to assist with LE dressing. The program requires 10 minutes each AM & HS. Will continue with program with emphasis on having resident complete shaving portion by himself without staff having to complete that task. Adapted from Care plan and restorative program from Odessa Memorial Hospital LTC unit. Used with permission.


P3 - h (Eating or Swallowing) RESIDENT #1 PROBLEM: Inability to initiate self-feeding related to Alzheimer’s dementia and cognitive deficits. GOAL: Will feed self with cues and guided maneuvering of hand to hold spoon and glass. INTERVENTIONS:  Load utensil and place in residents right hand.  Guide hand to self - feed if resident does not independently initiate activity.  Continue to hand resident glass intermittently throughout the meal & guide as needed.  Assure a calm, unhurried approach. Keep distractions to a minimum. Serve food promptly after seating. EVALUATION: (Quarterly Review) Continues to be able to self-feed once food loaded on utensil or handed glass with minimal cues and guided maneuvering of hand. Due to significant cognitive deficits does not independently initiate self-feeding of food or fluids. Accepts food readily. Intake remains 80-100% and weight is stable. Meal time takes approximately 20 minutes each session.

RESIDENT #2 PROBLEM: Feeding deficit related to dysphagia and R visual field cut secondary to CVA GOAL: To maintain ability to eat meals/fluids without aspirating. INTERVENTIONS:  Assist resident to UDR at specified times for meals (7AM, 12N, 5PM).  Set up tray for resident and prepare all items so ready to eat  Arrange food items on the left secondary to vision deficit to right eye.


 Allow resident to feed self independently with use of left arm. Cue resident to eat slowly and swallow foods before attempting another bite to lessen coughing/choking episodes. Ensure that food is cleared from mouth.  Observe/monitor that resident receives correct diet of dysphagia mechanical soft diet with nectar thick liquids.  Intervene if necessary when dry foods are noted i.e. cookies, crackers or if receives thin liquids. Note: Diet upgraded to include sandwiches with soft fillings which resident enjoys.  During coughing/choking episodes, observe for s/s’s of aspiration i.e. turning blue, particularly around the lips, inability to cough or mumble words. Alert LN immediately once these s/s’s are exhibited  Report to LN any decrease in function, eating ability, strength, endurance or ability to swallow. EVALUATION: Resident continues to be on an eating program secondary to dysphagia. Original goal was for resident to feed self in a comfortable environment. Staff has worked out a schedule for resident to eat meals early before other residents on the unit to lessen aggressive/agitated behavior. Meals served at 7am, 12n, 5pm respectively. Staff continues to monitor resident during meals and provide assistance as allowed by the resident. Resident continues to cough and turn red when consuming liquids/ foods. Staff continue to cue resident to swallow before taking next bite as well as cue resident to take small bites and to drink slowly. Resident continues to benefit from a dysphagia mechanical soft diet with nectar thick liquids. Eating program reevaluated to reflect goal of ―resident will not aspirate when eating‖. Goal is measurable since resident has had no episodes of aspiration. Program takes 25-30 minutes per meal. Used with permission from CRISTA Senior Community. P3 – i (Amputation/prosthesis care) RESIDENT #1 PROBLEM: Alteration in ADL self-performance r/t inability to insert right eye prosthesis. GOALS: Be able to insert right eye prosthesis independently within the next 3 weeks. Demonstrate care of eye socket and prosthesis.


INTERVENTIONS:  Cue at HS to remove eye prosthesis for cleaning.  Teach resident how to remove eye prosthesis.  Teach resident how to insert eye prosthesis.  Observe resident performance of eye socket care. Provide encouragement and positive feedback Notes: Instructions for each intervention may be modified with the words “teach”, “cue”, or “setup”, “assist”, etc. to allow for maximum resident participation. (Preceding example taken with permission from Rehabilitation and Restorative Nursing Guidelines, WHCA, 1998) EVALUATION: Resident continues to need step-by-step instructions for inserting, removing and caring for socket and prosthesis. L.N.’s continue to irrigate eye socket morning and evening. The resident is reluctant to direct normal saline solution into eye. States ― I don’t think I’ll ever be brave enough to do that!‖ Will assign nursing staff in-service coordinator to work with resident until resident’s self confidence is built -up and is independent in caring for socket. Discharge to an AFH is tentatively set next month. Program takes 15 minutes per day. P3 - j (Communication) RESIDENT #1 PROBLEM: Alteration in communication r/ t problem hearing, problem making self-understood, problem understanding others. GOALS: Resident know and use dominant ear; follow simple commands; continue to use communication board effectively to communicate needs; resident will complete single step tasks; resident will place and remove hearing aid QD. ; Resident will be able to communicate needs. INTERVENTIONS:  Use yes/no choices when possible  Use short, direct phrases  Eliminate environmental noises such as TV, radio, vacuum  Touch resident lightly to gain attention before speaking  Speak towards resident’s dominant ear--- (specify).

 Help position resident for comfort and best vision when using communication board.  Maintain eye contact with resident.  Give resident ample time to locate picture, word or sentence on communication board.  Demonstrate action you want resident to do using pantomime gestures, repeat gestures, as needed, i.e.; pantomime brushing your teeth.  Resident will know and use dominant ear. Note: Goals and Interventions adapted, with permission, from Restorative and Rehabilitative Nursing Guidelines WHCA, 1998. EVALUATION: Resident responds best to staff pantomiming task that they’re requesting resident to do. Resident’s sense of humor usually shows through, as he loves to laugh when staff pantomiming! Resident now gestures toward his ―good‖ ear. Needs a reminder to use hearing aid. Carries communication board in wheelchair and takes it out when trying to communicate. C. board is effective. The following care plan and evaluation example is written using a “first person” style where the resident is directing care needed from their perspective. RESIDENT #2 Mrs. ―A‖ PROBLEM: Since I had my stroke, I have trouble making my words come out right. People do not always understand what I am trying to say. GOAL: I want to be able to communicate my needs so that I am understood and I do not get frustrated and end up crying. I hope to see an improvement in the next 3 months. INTERVENTIONS:  I can respond to yes/no choices.  Ask me one question at a time and wait for me to answer before asking the next question.  Use my ―picture cues‖ booklet that is at my bedside or attached to my wheelchair to help me communicate.


I can either point to a picture or a series of words and you can ask me about it or you can point to the pictures or words and I can respond.  If I seem to be getting frustrated, remind me to slow down.  Tell me ―it’s ok‖ or ―I am doing a good job‖ when we talk, that way I feel good about my efforts.  Help me practice speaking as often as possible. The more I work at it the better I get. EVALUATION: During this past quarter, including the recent MDS assessment period, Mrs. ―A‖ has increased her communication efforts with all staff. The use of the ―picture cues‖ booklet has shown to be effective in reducing the periods of frustration and tearfulness. There have been only two episodes in the past month and they were during a family visit. Staff make regular contacts with her during personal care, meal times and activities. By asking yes/no questions and encouraging her to slow down, Mrs. ―A‖ is also beginning to add more words to her responses. For example, she may say, ―Yes, that’s what I want‖ or ―No, not right‖. The average amount of time per day that the interventions/techniques are provided is at least one hour. Will continue the program but will add some training for family members on the use of the interventions. The following care plan and evaluation is written using a “first person” style where the resident is directing care needed from their perspective. RESIDENT #3 Mrs. ―J‖ PROBLEM: I am unable to do anything for myself or speak to you. I have brain damage and a history of seizures. At times, I turn my head to the sound of your voice and can say ―Aah‖. GOAL: I want to increase my interaction (verbal, tactile auditory) communication and stimulation. I want to be able to answer questions to maintain my communication abilities. INTERVENTIONS:  Before speaking to Mrs. ―J‖, touch her lightly on the arm.  Use a calm, soothing voice  Stand directly in front of her and make eye contact

 Ask her ―If you are Mrs. ―J‖, say ―Aah‖; wait up to 60 seconds for her response, then  (B) Ask her to say, ―Aah‖; wait up to 60 seconds for her response.  Repeat this sequence up to 10 times but vary the format doing 5 of (A) then 5 of (B) or reverse and do (B) then (A).  Exaggerate your speech, sound cheerful and speak slowly  Reinforce her with verbal praise such as ―good job‖ or ―excellent‖ for every correct response; you may also provide a brief back rub with correct verbal responses.  Give her enough time to respond as she has a very delayed response.  Nursing staff are to document ―+‖ if able to respond and ―–― if unable to respond.  Document the amount of time the exercises take with a ―+‖ if 15 minutes or more, a ―-― if 8 minutes or more or a ―0‖ if less than 8 minutes EVALUATION: Mrs. ―J‖ is able to respond to verbal requests with a delayed verbal ―Aah‖. She makes eye contact with both verbal and tactile stimulation. She usually will suck and swallow prior to her verbal response. This past month, the program was provided at least 8 minutes twice daily. Will continue with current plan of care. Note: Adapted from care plan and restorative program from Hillcrest Manor. Used with permission.