H0200: Urinary Toileting Program
H0200: Urinary Toileting Program
Item Rationale
Health-related Quality of Life
An individualized, resident-centered toileting program may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence.
Determining the type of urinary incontinence can allow staff to provide more individualized programming or interventions to enhance the resident’s quality of life and functional status.
Many incontinent residents (including those with dementia) respond to a toileting program, especially during the day.
Planning for Care
The steps toward ensuring that the resident receives appropriate treatment and services to restore as much bladder function as possible are
determining if the resident is currently experiencing some level of incontinence or is at risk of developing urinary incontinence;
completing an accurate, thorough assessment of factors that may predispose the resident to having urinary incontinence; and
implementing appropriate, individualized interventions and modifying them as appropriate.
If the toileting program or bladder retraining leads to a decrease or resolution of incontinence, the program should be maintained.
Research has shown that one quarter to one third of residents will have a decrease or resolution of incontinence in response to a toileting program.
If incontinence is not decreased or resolved with a toileting trial, consider whether other reversible or treatable causes are present.
Residents may need to be referred to practitioners who specialize in diagnosing and treating conditions that affect bladder function.
Residents who do not respond to a toileting trial and for whom other reversible or treatable causes are not found should receive supportive management (such as checking the resident for incontinence and changing their brief if needed and providing good skin care).
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Steps for Assessment: H0200A, Trial of a Toileting Program
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The look-back period for this item is since the most recent admission/entry or reentry or since urinary incontinence was first noted within the facility. |
Review the medical record for evidence of a trial of an individualized, resident-centered toileting program. A toileting trial should include observations of at least 3 days of toileting patterns with prompting to toilet and of recording results in a bladder record or voiding diary. Toileting programs may have different names, e.g., habit training/scheduled voiding, bladder rehabilitation/bladder retraining.
Review records of voiding patterns (such as frequency, volume, duration, nighttime or daytime, quality of stream) over several days for those who are experiencing incontinence.
Voiding records help detect urinary patterns or intervals between incontinence episodes and facilitate providing care to avoid or reduce the frequency of episodes.
Simply tracking continence status using a bladder record or voiding diary should not be considered a trial of an individualized, resident-centered toileting program.
Residents should be reevaluated whenever there is a change in cognition, physical ability, or urinary tract function. Nursing home staff must use clinical judgment to determine when it is appropriate to reevaluate a resident’s ability to participate in a toileting trial or, if the toileting trial was unsuccessful, the need for a trial of a different toileting program.
Steps for Assessment: H0200B, Response to Trial Toileting Program
Review the resident’s responses as recorded during the toileting trial, noting any change in the number of incontinence episodes or degree of wetness the resident experiences.
Steps for Assessment: H0200C, Current Toileting Program or Trial
Review the medical record for evidence of a toileting program being used to manage incontinence during the 7-day look-back period. Note the number of days during the look- back period that the toileting program was implemented or carried out.
Look for documentation in the medical record showing that the following three requirements have been met:
implementation of an individualized, resident-specific toileting program that was based on an assessment of the resident’s unique voiding pattern;
evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, and a written report; and
notations of the resident’s response to the toileting program and subsequent evaluations, as needed.
Guidance for developing a toileting program may be obtained from sources found in Appendix C.
Coding Instructions H0200A, Toileting Program Trial
Code 0, no: if for any reason the resident did not undergo a toileting trial. This includes residents who are continent of urine with or without toileting assistance, or who use a permanent catheter or ostomy, as well as residents who prefer not to participate in a trial. Skip to Urinary Continence item (H0300).
Code 1, yes: for residents who underwent a trial of an individualized, resident-centered toileting program at least once since the most recent admission/entry or reentry or since urinary incontinence was first noted within the facility.
Code 9, unable to determine: if records cannot be obtained to determine if a trial toileting program has been attempted. If code 9, skip H0200B and go to H0200C, Current Toileting Program or Trial.
Coding Instructions H0200B, Toileting Program Trial Response
Code 0, no improvement: if the frequency of resident’s urinary incontinence did not decrease during the toileting trial.
Code 1, decreased wetness: if the resident’s urinary incontinence frequency decreased, but the resident remained incontinent. There is no quantitative definition of improvement. However, the improvement should be clinically meaningful—for example, having at least one less incontinent void per day than before the toileting program was implemented.
Code 2, completely dry (continent): if the resident becomes completely continent of urine, with no episodes of urinary incontinence during the toileting trial. (For residents who have undergone more than one toileting program trial during their stay, use the most recent trial to complete this item.)
Code 9, unable to determine or trial in progress: if the response to the toileting trial cannot be determined because information cannot be found or because the trial is still in progress.
Coding Instructions H0200C, Current Toileting Program
Code 0, no: if an individualized resident-centered toileting program (i.e., prompted voiding, scheduled toileting, or bladder training) is used less than 4 days of the 7-day look-back period to manage the resident’s urinary continence.
Code 1, yes: for residents who are being managed, during 4 or more days of the 7-day look-back period, with some type of systematic toileting program (i.e., bladder rehabilitation/bladder retraining, prompted voiding, habit training/scheduled voiding). Some residents prefer to not be awakened to toilet. If that resident, however, is on a toileting program during the day, code “yes.”
Coding Tips for H0200A-C
Toileting (or trial toileting) programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated that is consistent with the nursing home’s policies and procedures and current standards of practice. A toileting program does not refer to
simply tracking continence status,
changing pads or wet garments, and
random assistance with toileting or hygiene.
For a resident currently undergoing a trial of a toileting program,
H0200A would be coded 1, yes,
H0200B would be coded 9, unable to determine or trial in progress, and
H0200C would be coded 1, yes.
Examples
Resident H has a diagnosis of advanced Alzheimer’s disease. They are dependent on the staff for their ADLs, do not have the cognitive ability to void in the toilet or other appropriate receptacle, and are totally incontinent. Their voiding assessment/diary indicates no pattern to their incontinence. Their care plan states that due to their total incontinence, staff should follow the facility standard policy for incontinence, which is to check and change every 2 hours while awake and apply a superabsorbent brief at bedtime so as not to disturb their sleep.
Coding: H0200A would be coded as 0, no. H0200B and H0200C would be skipped.
Rationale: Based on this resident’s voiding assessment/diary, there was no pattern to their incontinence. Therefore, H0200A would be coded as 0, no. Due to total incontinence a toileting program is not appropriate for this resident. Since H0200A is coded 0, no, skip to H0300, Urinary Continence.
Resident M., who has a diagnosis of congestive heart failure (CHF) and a history of left-sided hemiplegia from a previous stroke, has had an increase in urinary incontinence. The team has assessed them for a reversible cause of the incontinence and has evaluated their voiding pattern using a voiding assessment/diary. After completing the assessment, it was determined that incontinence episodes could be reduced. A plan was developed and implemented that called for toileting every hour for 4 hours after receiving their 8 a.m. diuretic, then every 3 hours until bedtime at 9 p.m. The team has communicated this approach to the resident and the care team and has placed these interventions in the care plan. The team will reevaluate the resident’s response to the plan after 1 month and adjust as needed.
Coding: H0200A would be coded as 1, yes.
H0200B would be coded as 9, unable to determine or trial in progress.
H0200C would be coded as 1, current toileting program or trial. Rationale: Based on this resident’s voiding assessment/diary, it was determined that this resident could benefit from a toileting program. Therefore H0200A is coded as 1,
yes. Based on the assessment it was determined that incontinence episodes could be
reduced, therefore H0200B is coded as 9, unable to determine or trial in progress. An individualized plan has been developed, implemented, and communicated to the resident and staff, therefore H0200C is coded as 1, current toileting program or trial.
