CMS SOM App. PP, Tag F677

the necessary services to maintain good nutrition, grooming, and personal and oral

hygiene; and

DEFINITIONS

“Oral care” refers to the maintenance of a healthy mouth, which includes not only teeth,

but the lips, gums, and supporting tissues. This involves not only activities such as

brushing of teeth or oral appliances, but also maintenance of oral mucosa.

“Speech, language or other functional communication systems” refers to the resident’s

ability to effectively communicate requests, needs, opinions, and urgent problems; to

express emotion, to listen to others and to participate in social conversation whether in

speech, writing, gesture, behavior, or a combination of these (e.g., a communication

board or electronic augmentative communication device).

“Assistance with the bathroom” refers to the resident’s ability to use the toilet room (or

commode, bedpan, urinal); transfer on/off the toilet, clean themselves, change absorbent

pads or briefs, manage ostomy or catheter, and adjust clothes.

“Transfer” refers to resident’s ability to move between surfaces - to/from: bed, chair,

wheelchair, and standing positions. (Excludes to/from bath/toilet.)

GUIDANCE

The existence of a clinical diagnosis shall not justify a decline in a resident’s ability to

perform ADLs unless the resident’s clinical picture reflects the normal progression of the

disease/ condition has resulted in an unavoidable decline in the resident’s ability to

perform ADLs. Conditions which may demonstrate an unavoidable decline in the

resident’s ability to perform ADLs include but are not limited to the following:

• The natural progression of a debilitating disease with known functional decline;

• The onset of an acute episode causing physical or mental disability while the

resident is receiving care to restore or maintain functional abilities; and

• The resident’s or his/her representative’s decision to refuse care and treatment to

restore or maintain functional abilities after efforts by the facility to inform and

educate about the benefits/risks of the proposed care and treatment; counsel

and/or offer alternatives to the resident or representative. The decision to refuse

care and treatment must be documented in the clinical record. Documentation

must include interventions identified on the care plan and in place to minimize or

decrease functional loss that were refused by the resident or resident’s

representative and any interventions that were substituted with consent of the

resident and/or representative to minimize further decline. NOTE: In some cases,

residents with dementia may resist the manner in which care is being provided, or

attempted, which can be misinterpreted as declination of care. In some cases the

resident with dementia does not understand what is happening, or may be fearful

of unfamiliar staff, or may be anxious or frustrated due to inability to

communicate. Facility staff are responsible to attempt to identify the underlying

cause of the “refusal/declination” of care.

• Note also that depression is a potential cause of excess disability and, where

appropriate, therapeutic interventions should be initiated. Follow up if the resident

shows signs/symptoms of depression even if not indicated on his or her MDS.

If it is determined that the resident’s inability to perform ADLs occurred after admission

due to an unavoidable decline, such as the progression of the resident’s disease process,

surveyors must still determine that interventions to assist the resident are identified and

implemented immediately.

Appropriate treatment and services includes all care provided to residents by staff,

contractors, or volunteers of the facility to maximize the resident’s functional abilities.

This includes pain relief and control, especially when it is causing a decline or a decrease

in the quality of life of the resident.

NOTE: For evaluating a resident’s ADLs and determining whether a resident’s abilities

have declined, improved, or stayed the same within the last twelve months, the following

definitions as specified in the State’s Resident Assessment Instrument (RAI) Manual are

used in reference to the Assessment Reference Date (ARD):

• Independent: if the resident completes the activity by themself with no assistance

from a helper.

• Setup or clean-up assistance: if the helper sets up or cleans up; resident completes

activity. Helper assists only prior to or following the activity, but not during the

activity. For example, the resident requires assistance cutting up food or opening

container or requires setup of hygiene item(s) or assistive device(s).

• Supervision or touching assistance: if the helper provides verbal cues or

touching/steadying/contact guard assistance as resident completes activity.

• Assistance may be provided throughout the activity or intermittently.

• Partial/moderate assistance: if the helper does LESS THAN HALF the effort.

Helper lifts, holds, or supports trunk or limbs, but provides less than half the

effort.

• Substantial/maximal assistance: if the helper does MORE THAN HALF the

effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

• Dependent: if the helper does ALL of the effort. Resident does none of the effort

to complete the activity; or the assistance of two or more helpers is required for

the resident to complete the activity.

PROCEDURES

Use the Activities of Daily Living Critical Element (CE) Pathway, along with the

above interpretive guidelines when determining if facility practices are in place to

identify, evaluate, and intervene to, maintain, improve, or prevent an avoidable decline in

ADLs. In addition, use this pathway for the resident who is unable to perform ADLs.

Briefly review the most recent comprehensive assessment, care plan, physician orders, as

well as ADL documentation/flow sheets on various shifts, to identify whether the facility

has:

• Recognized and assessed an inability to perform ADLs, or a risk for decline in

any ability they have to perform ADLs;

• Developed and implemented interventions in accordance with the resident’s

assessed needs, goals for care, preferences, and recognized standards of practice

that address the identified limitations in ability to perform ADLs;

• Monitored and evaluated the resident’s response to care plan interventions and

treatment; and

• Revised the approaches as appropriate.

NOTE: For concerns related to facility failure to provide care, services, equipment or

assistance to a resident with limited mobility, refer to F688, Mobility.