|Documentation-||For a patient to be cited as level 4, documentation by a licensed clinician |
must exist which describes the following three components:
o A description of the patient's decubitus.
o Circumstance or medical condition which led to the decubitus.
o An active treatment plan.
|#0 No reddened skin or breakdown.|
#1 Reddened skin, potential breakdown.
#2 Blushed skin, dusty colored, superficial layer of broken or
#3 Subcutaneous skin is broken down.
#4 Necrotic breakdown of skin and subcutaneous tissue which may
involve muscle, fascia and bone.
#5 Patient is a level 4, but the documentation qualifier has not been
|17. MEDICAL CONDITIONS: For a AYES@ to be answered for any of these conditions, all of the following qualifiers must be met:|
|Time Period-||Condition must have existed during the past four weeks. |
(The only exception is to use the past twelve weeks for
question 17H, urinary tract infection.
|Documentation-||Written support exists that the patient has the condition.|
|Definitions-||See chart below. (Examples are for clarification and are not|
intended to be all-inclusive.)
|DEFINITION||EXAMPLES OF CAUSES||EXAMPLES OF TREATMENTS|
|17A.||COMATOSE: Unconscious, cannot be aroused, and at most can respond only to powerful stimuli. The coma must be present for at least four days.||Brain insult|
Cerebral vascular accident
|Total ADL Care|
Intake and output
|17B.||DEHYDRATION: Excessive loss of body fluids requiring immediate medical treatment and ADL care.||Fever|
Acute urinary tract infections
|Intake & output|
Electrolyte lab tests
|17C.||INTERNAL BLEEDING: Blood loss stemming from a subacute or chronic condition (e.g., gastrointestinal, respiratory or genito-urinary conditions) which may result in low blood pressure and hemoglobin, pallor, dizziness, fatigue, rapid respiration.||Use only the causes presented|
in the definition. Exclude external hemorrhoids and other minor blood loss which is not dangerous and requires only minor intervention
|Critical monitoring of |
Use of blood pressure elevators
Blood likely to be needed every 60 days
|17D.||STASIS ULCER: Open lesion, usually in lower extremities, caused by decreased blood flow from chronic venous insufficiency.||Severe edema |
|Sterile dressing |
|17E.||TERMINALLY ILL: Professional prognosis (judgement) is that patient is rapidly deteriorating and will likely die within three months.||End stages of:|
|17F.||CONTRACTURES: Shortening and tightening of ligaments and muscles resulting in loss of joint movement. Determine whether range of motion loss is actually due to spasticity, paralysis or joint pain. It is important to observe the patient to confirm whether a contracture exists and check the chart for confirmatory documentation.|
|To qualify as AYES@ on the PRI the following qualifiers must be met:|
|1. The contracture must be documented by a physician, physical therapist or occupational therapist.|
|2. The status of the contracture must be reevaluated and documented by the physician, physical therapist or occupational therapist on an annual basis.|
There does not need to be an active treatment plan to enter AYES@ to contractures.
|17G.||DIABETES MELLITUS: A metabolic disorder in which the ability to oxidize carbohydrates is compromised due to inadequate pancreatic activity resulting in disturbance of normal insulin production. This may or may not be the primary problem (Q. 29) or primary diagnosis. It should be diagnosed by a physician. Include any degree of diabetes, stable or unstable, and any manner it is controlled.||Destruction/malfunction of the pancreas |
Exclude hypoglycemia or hyperglycemia which may be a diabetic condition, but by itself does not constitute diabetes mellitus
|Special diet |
|17H.||URINARY TRACT INFECTION: During the past twelve weeks symptoms of a UTI have been exhibited or it has been diagnosed by lab tests. Symptoms may include frequent voiding, foul smelling urine, voiding small amounts cloudy urine, sediment and an elevated temperature. May or may not be the primary problem under Q.29. Include as a UTI if it has not been confirmed yet by lab tests, but the symptoms are present. Include patients who appear asymptomatic, but whose lab values are positive (e.g., mentally confused or incontinent patients).||Exclude if symptoms are present, but the lab values are negative||Antibiotics |
|17I.||HIV INFECTION SYMPTOMATIC: HIV (Human Immunodeficiency Virus) Infection, Symptomatic: Includes Acquired Immunodeficiency Syndrome (AIDS) and HIV related illnesses. The patient has been tested for HIV infection AND a positive finding is documented AND the patient has had symptoms, documented by a physician, nurse practitioner, (in conformance with a written practice agreement with a physician), or physician assistant as related to the HIV infection. Symptoms include but are not limited to abnormal weight loss, respiratory abnormalities, anemia, persistent fever, fatigue and diarrhea. Symptoms need not have occurred in the past four weeks. Exclude patients who have tested positive for HIV infection and have not become symptomatic, and patients who have not received the results of the HIV test.|
|17J.||ACCIDENT: An event resulting in serious bodily harm, such as a fracture, a laceration which requires closure, a second or third degree burn or an injury requiring admission to a hospital.|
|To qualify as AYES@ on the PRI the following qualifier must be met:|
1. During the past six months serious bodily harm occurred as the result of one or more accidents.
|17K.||VENTILATOR DEPENDENT: A patient who has been admitted to a skilled nursing facility on a ventilator or has been ventilator dependent within five (5) days prior to admission to the skilled nursing facility. Patients who are in the process of being weaned off of ventilator support will qualify for this category for one month after extubation if they are receiving active respiratory rehabilitation services during that period. Patients in the facility who decompensate and require intubation also qualify for this category.|
|All services shall be Provided in accordance with Sections 416.13, 711.5 and 713.21 of Chapter V of Title 10 of the Official Compilation of Codes Rules and Regulations of the State of New York.|
|18. MEDICAL TREATMENTS: For a AYES@ to be answered for any of these, the following qualifiers must be met:|
|Time Period-||Treatment must have been given during the past four weeks in conformance with the frequency requirements cited below and|
|Frequency-||As specified in the chart below. (The only exception is to use the past twelve weeks for question 18L, catheter.)|
|Documentation-||Physician order, nurse practitioner order (in conformance with a written practice agreement with a physician), or appropriately cosigned physician assistant order specifies that treatment should be given and includes frequency as cited below, where appropriate.|
|Exclusions-||See chart on next page.|
|18A.||TRACHEOSTOMY CARE: Care for a tracheostomy, including suctioning. Exclude any self-care patients who do not need daily staff help.||Daily||Self-care patients|
|18B.||SUCTIONING: Nasal or oral techniques for clearing away fluid or secretions. May be for a respiratory problem.||Daily||Any tracheostomy|
|18C.||OXYGEN THERAPY: Administration of oxygen by nasal catheter, mask (nasal or oronasal), funnel/cone, or oxygen tent for conditions resulting from oxygen deficiency (e.g., cardiopulmonary condition).||Daily||Inhalators|
Oxygen in room, but not in use
|18D.||RESPIRATORY CARE: Care for any portion of the respiratory tract, especially the lungs (for example COPD, pneumonia). This care may include one or more of the following: percussion or cupping, postural drainage, positive pressure machine, possibly oxygen to administer drugs, etc.||Daily||Suctioning|
|18E.||NASAL GASTRIC FEEDING: Primary food intake is by a tube inserted into nasal passage; resorted to when it is the only route to the stomach.||None||None|
Gastrostomy not applicable
|18F.||PARENTERAL FEEDING: Intravenous or subcutaneous route for the administration of fluids used to maintain fluid, nutritional intake, electrolyte balance (e.g., comatose, damaged stomach).||None||None|
Gastrostomy not applicable
|18G.||WOUND CARE: Subcutaneous lesion(s) resulting from surgery, trauma, or open cancerous ulcers.||Care has been provided or is professionally judged to be needed for at least 3 consecutive weeks||Decubiti |
|18H.||CHEMOTHERAPY: Treatment of carcinoma through IV and/or oral chemical agents, as ordered by a physician, nurse practitioner, (in conformance with a written practice agreement with a physician), or physician assistant when the physician assistant’s order is appropriately cosigned. (Patient may have to go to a hospital for treatment.)||None||None|
|18I.||TRANSFUSIONS: Introduction of whole blood or blood components directly into the blood stream. (Patients may have to go to a hospital for treatment.)||None||None|
|18J.||DIALYSIS: The process of separating components, as in kidney dialysis|
(e.g., renal failures, leukemia, blood dyscrasia). Patient may have to go to a hospital for treatment.
|18K.||BOWEL AND/OR BLADDER REHABILITATION: The goal of this treatment is to gain or regain optimal bowel and/or bladder function and to re-establish a pattern. It is much more than just a toileting schedule or a maintenance/conditioning program. Rather it is an intense treatment which is very specific and unique for each patient and is of short term duration (i.e., usually not longer than six weeks). NOT all patients at level 5 under Toileting Q.22 may be a "YES@ with this question. The specific definition for bladder rehabilitation differs from bowel rehabilitation; refer below:||Very specific|
for each patient
Restorative toileting program but does not meet the treatment requirements specified in the definitions
|Bladder rehabilitation: Will generally include these step-by-step procedures which are closely monitored, evaluated and documented: (1) mental and physical assessment of the patient to determine training capacity; (2) a 24 hour flow sheet or chart documenting voiding progress; (3) possibly increased fluid intake during the daytime; (4) careful attention to skin care; (5) prevention of constipation; (6) in the beginning may be toileted 8 to 12 times per day with decreased frequency with progress.|
|Bowl rehabilitation: A program to prevent chronic constipation/impaction. The plan will generally include: (1) assessment of past bowel movements, relevant medical problems, medication use; (2) a dietary regimen of increased fluids and bulk |
(e.g., bran, fruits); (3) regular toileting for purposes of bowel evacuation; (4) use of glycerine suppositories or laxatives; (5) documentation on a worksheet or Kardex.
|Exclude a bowel|
which controls bowel
intinence by development of a
|18L.||CATHETER: During the past twelve weeks, an indwelling or external catheter has been needed. Indwelling catheter has been used for any duration during the past twelve weeks. The external catheter was used on a continuous basis (with proper removal and replacement during this period) for one or more days during the past twelve weeks. A physician order is required for an indwelling catheter; for an external catheter a physician order is not required.||Exclude catheters|
used to empty the
bladder once, secure
a specimen or instill medication
|18M.||PHYSICAL RESTRAINTS: A physical device used to restrict resident movement. Physical restraints include belts, vests, cuffs, mitts, jackets, harnesses and geriatric chairs.||At least two continuous|
for at least 14 days during the past four weeks.
|Exclude all of following:|
o Medication use for the sole purpose of modifying residents behavior
o Application only at night
o Application for less than two continuous daytime hours for 14 days
o Devices which residents can release/remove such as, velcro seatbelts on wheelchairs
o Residents who are bed bound
o Side rails, locked doors/gates, domes
|To Qualify as AYES@ on the PRI the following qualifiers must be met:|
1. The restraint must have been applied for at least two continuous daytime hours for at least 14 days during the past four weeks. Daytime includes the time from when the resident gets up in the morning to when the resident goes to bed at night.
2. An assessment of need for the physical restraint must be written by an M.D. or R.N.
3. The comprehensive care plan based on the assessment must include a written physician's order and specific nursing interventions regarding use of the physical restraint.
|NEW ADMISSIONS: If a patient is a new admission and will require the use of a physical restraint for at least two continuous daytime hours for at least 14 days as specified by the physician order, then enter AYES@ on the PRI.|
|III. ACTIVITIES OF DAILY LIVING: EATING, MOBILITY, TRANSFER, TOILETING|
Use the following qualifiers in answering each ADL question:
|Time Period-||Past four weeks.|
|Frequency-||Asses how the patient completed each ADL 60% or more of the time performed (since ADL status may fluctuate during the day or over the past four weeks.)|
CHANGED CONDITION RULE: When a patient's ADL has improved or deteriorated during the past four weeks and this course is unlikely to change, measure the ADL according to its status during the past seven days.
|Definitions-||SUPERVISION means verbal encouragement and observation, not physical hands-on care.|
ASSISTANCE means physical hands-on care.
INTERMITTENT means that a staff person does not have to be present during the entire activity, nor does the help have to be on a one-to-one basis.
CONSTANT means one-to-one care that requires a staff person to be present during the entire activity. If the staff person is not present, the patient will not complete the activity.
Note how these terms are used together in the ADLs. For example, there is intermittent supervision and intermittent assistance.
|Time Period-||Past four weeks.|
|Frequency-||As stated in the responses to each behavioral question.|
|Documentation-||To qualify a patient as LEVEL 4 or to qualify the patient as a "YES" to |
HALLUCINATIONS, the following conditions must be met:
o Active treatment plan for the behavioral problem must be in current use.
o Psychiatric assessment by a recognized professional with psychiatric
training/education must exist to support the fact that the patient has a severe
behavioral problem. The problem addressed by this assessment must still be
exhibited by the patient.
|Definitions-||The terms used on the PRI should be interpreted only as they are defined below:|
o PATIENT'S BEHAVIOR: Measure it as displayed with the behavior modification
and treatment plan in effect during the past four weeks.
o DISRUPTION: Through verbal outbursts and/or physical actions, the patient
interferes with the staff and/or other patients. This interference causes the staff
to stop or change what they are doing immediately to control the situation. Without
this staff assistance, the disruption would persist or a problem would occur.
o NONDISRUPTION: Verbal outbursts and/or physical actions by the patient
may be irritating, but do not create a need for immediate action by the staff.
o UNPREDICTABLE BEHAVIOR: The staff cannot predict when (that is, under
what circumstances) the patient will exhibit the behavioral problem. There is no
o PREDICTABLE BEHAVIOR: Based on observations and experiences with
the patient, the staff can discern when a patient will exhibit a behavioral problem
and can plan appropriate responses in advance. The behavioral problem may
occur during activities of daily living (for example, bathing), specific treatments
(for example, contracture care, ambulation exercises), or when criticized, bumped
|27. *LEVEL QUESTION:||**QUALIFIERS (see level 4 below)|
|QUALIFIERS FOR LEVEL||MAINTENANCE THERAPY = LEVEL 2||RESTORATIVE THERAPY = LEVEL 3|
|DOCUMENTATION QUALIFIERS: POTENTIAL FOR INCREASED FUNCTIONAL / ADL ABILITY||None.|
Therapy is provided to maintain and/or retard deterioration of current functional/ADL status. Therapy plan of care and progress notes should support that patient has no potential for further or any significant improvement.
|There is positive potential for improved functional status within a short and predictable period of time. Therapy plan of care and progress notes should support that patient has this potential/is improving.|
|PHYSICIAN ORDER, NURSE PRACTITIONER ORDER (IN CONFORMANCE WITH A WRITTEN PRACTICE AGREEMENT WITH A PHYSICIAN), OR APPROPRIATELY COSIGNED PHYSICIAN ASSISTANT ORDER||Yes||Yes, monthly|
|PROGRAM DESIGN AND EVALUATION QUALIFIER||Licensed professional person with a 4 year, specialized therapy degree evaluates program on a monthly basis.||Licensed professional person with a 4 year, specialized therapy degree evaluates program on a monthly basis.|
|TIME PERIOD QUALIFIER||Treatments have been provided during the past four weeks.||Treatments have been provided during the past four weeks.|
|NEW ADMISSION QUALIFIER||Not Applicable||New admissions of less than four weeks can be marked for restorative therapy if:|
o There is a physician order, nurse practitioner order (in conformance with a written agreement with a physician), or appropriately cosigned physician assistant order for therapy and patient is receiving it.
o The licensed therapist has documented in the care/plan that therapy is needed for at least 4 weeks.
o A new admission includes readmission to a residential health care facility.
|* After completion of the ALevel@ question, proceed to the separate ADays@ and ATime@ qualifiers on the next page.|
** QUALIFIERS NOT MET = LEVEL 4
ENTER LEVEL 4 IF ANY ONE OF THE QUALIFIERS UNDER QUALIFIERS FOR LEVELS 2 OR 3 IS NOT MET.
|27. DAYS AND TIME PER WEEK QUESTION: QUALIFIERS*|
|QUALIFIERS FOR DAYS AND TIME*||MAINTENANCE THERAPY|
(i.e.,level 2 or 4 under ALevel@ question)
(i.e., If level 3 or 4 under ALevel@ question)
|TYPE OF THERAPY SESSION||Count only one-to-one care. Exclude group sessions (e.g., PT exercise session, OT cooking session).||Count only one-to-one care. Exclude group sessions (e.g., PT exercise session, OT cooking session).|
|SPECIALIZED PROFESSIONAL ON-SITE (ON-SITE MEANS WITHIN THE FACILITY)||A certified (2 year) or licensed (4 year) specialized professional is on-site supervising or providing therapy.||A licensed (4 year) specialized professional is on-site supervising or providing care. (Do not include care provided by PT or OT aides).|
|* QUALIFIERS NOT MET: DO NOT ENTER ON THE PRI ANY DAYS AND TIME OF THERAPY WHICH DO NOT MEET BOTH THE QUALIFIERS UNDER EACH LEVEL OF THERAPY.|
|28. NUMBER OF PHYSICIAN VISITS: Enter A0" (zero) unless the patient need qualifiers stated below are met. If, and ONLY if, the patient meets all the patient need qualifiers, then enter the number of physician visits, nurse practitioner visits (in conformance with a written practice agreement with a physician), or physician assistant visits that meet the physician, nurse practitioner, or physician assistant visit qualifiers|
|o PATIENT TYPE/NEED QUALIFIERS: The patient has a medical condition that (1) is unstable and changing or (2) is stable, but there is high risk of instability. If this patient is not closely monitored and treated by medical staff, an acute episode or severe deterioration can result. Documentation must support that the patient is of this type (for example, terminally ill, acute episode, recent hospitalization, post-operative).|
|o PHYSICIAN, NURSE PRACTITIONER, OR PHYSICIAN ASSISTANT VISIT QUALIFIER: If, and only if, the patient meets the PATIENT TYPE/NEED QUALIFIER, then enter the number of physician visits, nurse practitioner visits (in conformance with a written practice agreement with a physician), or physician assistant visits during the past four weeks that meet the following qualifications:|
|o A visit qualifies only if there is physician, nurse practitioner, or physician assistant documentation that she/he has personally examined the patient to address the pertinent medical problem. The physician, nurse practitioner, or physician assistant must make a notation or documentation in the medical record as to the result of the visit for the unstable medical condition (e.g., change medications, renew treatment orders, nursing orders, order lab tests).|
o Do not include phone calls as a visit nor visits which could have been accomplished over the phone.
o A visit qualifies whether it is on-site or off-site, as long as the patient is not an inpatient in a hospital/other facility.
|o||Antidepressants-||Amitriptyline (Elavil); Imipramine (Tofranil); Doxepin (Sinequan); Tranylcpromine (Parnate); Phenelzine (Nardil)|
|o||Anticholinergics-||Benztropine (Cogentin); Trihexyphenidyl (Artane)|
|o||Antihistamines-||Diphenhydramine (Benadryl); Hydroxyzine (Atarax)|
|o||Anxiolytics-||Chlordiazepoxide (Librium); Diazepam (Valium)|
|o||Cerebral Stimulants-||Methylphenidate (Ritalin); Amphetamines (Benzedrine)|
|o||Neuroleptics-||Phenothiazines; Thiothixene (Navane); Haloperidol (Haldol); Chlorpromezine (Thorazine); Thioridazine (Mellaril)|
|o||Somnifacients-||Barbituates (Nembutal); Temazepam (Restoril); Glutethimide (Doriden); Flurazepam (Dalmane)|